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A TREATISE 



THE SCIENCE AND PRACTICE 



OF 



MIDWIFERY. 






/ 



BY 



W. S. PLAYFAIR, M.D., F.R.C.P., 

PHrsiCIAN-AOCOUCHEUR TO H. I AND R. H. THE DUCHESS OF EDINBURGH ; PROFESSOR OF OBSTETRIC 

MEDICINE IN KING'S COLLEGE ; PHYSICIAN FOR THE DISEASES OF WOMEN AND CHILDREN TO 

KING'S COLLEGE HOSPITAL ; CONSULTING PHYSICIAN TO THE EVELINA HOSPITAL FOR 

CHILDREN J EXAMINER IN MIDWIFERY TO THE UNIVERSITY OF LONDON J LATE 

EXAMINER IN M ID WIFERY TO THE ROYAL COLLEGE OF PHYSICIANS J 

AND VICE-PRESIDENT OF THE OBSTETRICAL SOCIETY OF LONDON. 



WITH NOTES AND ADDITIONS 




BY 

EOBEET P. HARRIS, M.D. 
SECOND AMERICAN 

FROM THE 

SECOND AND REVISED LONDON EDITION. 



WITH TWO PLATES AND ONE HUNDRED AND EIGHTY-TWO ILLUSTRATIONS. 





PHILADELPHIA: 

H E K" E Y C LEA 

1878. 






S2A 



no. 



Entered according to Act of Congress, in the year 1878, by 

HENRY C. LEA, 
in the Office of the Librarian of Congress, at Washington. 



COLLINS, PRINTER. 



TO 



T. GAILLARD THOMAS, M.D., 

PROFESSOR OF OBSTETRICS 
IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK. 



Dear Dr. Thomas : 

I am desirous of marking my gratitude for the kind reception of my 
book in America, where so much valuable obstetric work has been done, by 
associating with the Second Edition the name of one whose many important 
contributions to the branch of Medicine of which it treats have gained for 
him so great and so well-deserved a reputation. I could wish that it were 
more worthy of the honor you do me in allowing me to dedicate it to you ; 
but, such as it is, I beg you to accept it as a mark of the high esteem in 
which you, as well as your fellow laborers in obstetric science, are held in 
the mother country. 

I am, very faithfully yours, 

W. S. PL A YF AIR. 

31 George Street, Hanover Square, 1878. 



AMERICAN PUBLISHER'S NOTICE. 



In reprinting this work from the second London edition, the 
position which it has assumed in this country as an authoritative 
text-book seemed to call for such additions as would render it more 
completely suited to the wants of the American student. 

A careful scrutiny on the part of the Editor has shown that but 
little was required for this purpose ; the work, though condensed, 
being very complete and accurate. With the exception of numerous 
short foot-notes, therefore, his additions have been confined to points 
in which the experience and practice of American obstetricians differ 
from those of England, and to one or two matters of recent interest. 
These are chiefly the Cesarean Section; the varieties of forceps, 
and their use in the dorsal decubitus ; dystocia from tetanoid uterine 
constriction ; and the intra- venous injection of milk, as a substitute 
for the transfusion of blood. All additions will be found distin- 
guished from the text by inclosure in brackets [ — ]. 

Philadelphia, September, 1878. 




PREFACE TO THE SECOND EDITION. 



In presenting a Second Edition the Author has very gratefully to 
acknowledge the favorable reception which has been accorded by 
the Profession to his work, as indicated by the rapid exhaustion of 
an unusually large impression. He trusts that the revision to 
which the book has been subjected may render it still more 
worthy of being used as a guide in the study of the important 
and responsible branch of medicine of which it treats. He has 
again to tender his cordial thanks to his colleague, Dr. Hayes, for 
the trouble he has taken in assisting him in passing it through the 
press. 

31 George Street, Hanover Square, 
March, 1878. 



PREFACE TO THE FIRST EDITION 



Those who "have studied the progress of Midwifery know that 
there is no department of medicine in which more has been done 
of late years, and none in which modern views of practice differ 
more widely from those prevalent only a short time ago. The 
Author's object has been to place in the hands of his readers an 
epitome of the science and practice of midwifery which embodies 
all recent advances. He is aware that on certain important points 
he has recommended practice which not long ago would have been 
considered heterodox in the extreme, and which, even now, will not 
meet with general approval. He has, however, the satisfaction of 
knowing 1 that he has onlv done so after verv deliberate reflection, 
and with the profound conviction that such changes are right, and 
that they will stand the test of experience. He has endeavored to 
dwell especially on the practical part of the subject, so as to make 
the work a useful guide in this most anxious and responsible branch 
of the profession. It is admitted by all, that emergencies and 
difficulties arise more often in this than in any other branch of 
practice ; and there is no part of the practitioner's work which 
requires more thorough knowledge or greater experience. It is, 
moreover, a lamentable fact that students generally leave their 
schools more ignorant of obstetrics than any other subject, So long- 
as the absurd regulations exist, which oblige the lecturer on mid- 
wifery to attempt the impossible task of teaching obstetrics in a 
short three months' course — an absurdity which has over and over 
again been pointed out — such must of necessity be the case. This 
must be the Author's excuse for dwelling on many topics at greater 



X PREFACE TO THE FIRST EDITION. 

length than some will doubtless think their importance merits 
since he desires to place in the hands of his students a work which 
may in some measure supply the inevitable defects of his lectures. 

Many of the illustrations are copied from previous authors, while 
some are original. The following quotation from the preface to 
Tyler Smith's " Manual of Obstetrics" will explain why the source 
of the copied woodcuts has not been in each instance acknowledged : 
" When I began to publish, I determined to give the authority for 
every woodcut copied from other works; I soon found, however, 
that obstetric authors of all countries, from the time of Mauri- 
ceau downwards, had copied each other so freely without acknowl- 
edgment as to render it difficult or impossible to trace the 
originals." 

The Author has to express his acknowledgments to many 
friends for their kind assistance by the loan of illustrations and 
otherwise, and more especially to his colleague, Dr. Hayes, for 
his valuable aid in passing the work through the press. 



31 George Street, Hanover Square, 
March, 1876. 



CONTENTS 



PART I. 

ANATOMY AND PHYSIOLOGY OF THE ORGANS CONCERNED IN 

PARTURITION. 



CHAPTER I. 

THE BOXY PELVIS. 

PArJE 

Its importance — Formation of Pelvis — The os innominatum : its three divisions — 
Separation between the True and False Pelvis — the Sacrum and Coccyx — Me- 
chanical relations of the Sacrum — Pelvic articulations and ligaments — Move- 
ments of the Pelvic joints — The Pelvis as a whole — Differences in the two sexes 
— Measurements of the Pelvis — Its diameters, planes, and axes — Development 
of the Pelvis — Soft parts in connection with the Pelvis 25 

CHAPTER II. 

THE FEMALE GENERATIVE ORGANS. 

Division according to Function : 1. External or Copulative ; 2. Internal or Form- 
ative Organs — Mons Veneris — Labia majora and minora — The Clitoris — The 
vestibule and orifice of Urethra — Passing of the female catheter — Orifice of 
Vagina — The Hymen — The glands of the Vulva — The Perineum — The Vagina 
— The Uterus ; its position and anatomy — The ligaments of the Uterus — The 
Parovarium — The Fallopian Tubes — The Ovaries — The Graafian Follicles, and 
the Ova 41 

CHAPTER III. 

OVULATION AND MENSTRUATION. 

Functions of the Ovary — Changes in the Graafian Follicle: 1. Maturation; 2. 
Escape of the Ovum — Formation of the Corpus Luteum — Quality and source of 
the Menstrual blood — Theory of Menstruation — Purpose of the Menstrual loss 
— Vicarious Menstruation — Cessation of Menstruation 71 



Xll CONTENTS. 

PAET II. 

PREGNANCY. 



CHAPTER I. 

CONCEPTION AND GENERATION. 

PAGE 

The Semen — Site and mode of Impregnation — Changes in the Ovum — Cleavage 
of the Yelk — The Decidua and its formation — Formation of the Amnion— The 
Umbilical Vesicle and Allantois — The Liquor Amnii and its uses — The Chorion 
— The Placenta : its formation, anatomy, and functions . . . . .84 

CHAPTER II. 

THE ANATOMY AND PHYSIOLOGY OF THE FOETUS. 

Appearance of the Foetus at various stages of development — Anatomy of the Foetal 
Head — The Sutures and Fontanelles — Influence of Sex and Race on the Foetal 
Head — Position of the Foetus in utero — Functions of the Foetus — The Foetal 
Circulation 107 

CHAPTER III. 

PREGNANCY. 

Changes in the form and dimensions of the Uterus — Changes in the Cervix — 
Changes in the texture of the Uterine Tissues, the Peritoneal, Muscular, and 
Mucous Coats — General modifications in the Body produced by Pregnancy . 123 

CHAPTER IV. 

SIGNS AND DIAGNOSIS OF PREGNANCY. 

Signs of a fruitful Conception — Cessation of Menstruation — Sympathetic disturb- 
ances : Morning Sickness, etc. — Mammary Changes — Enlargement of the Ab- 
domen — Quickening — Intermittent Uterine contractions — Vaginal Signs of 
Pregnancy — Ballottement, etc. — Auscultatory Signs of Pregnancy — Foetal Pul- 
sations — Uterine Souffle, etc 133 

CHAPTER V. 

THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY SPURIOUS PREGNANCY 

DURATION OF PREGNANCY SIGNS OF RECENT DELIVERY. 

Adipose enlargement of the Abdomen — Distension of the Uterus by retained 
Menses, etc. — Congestive enlargement of Uterus — Ascites — Uterine and Ovarian 
Tumors — Spurious Pregnancy: its Causes, Symptoms, and Diagnosis — The 
duration of Pregnancy — Sources of Fallacy — Methods of Predicting Date of De- 
livery — Protraction of Pregnancy — Signs of recent Delivery .... 148 



CONTENTS. Xlll 



CHAPTER VI. 

ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, SUPER- 

FCETATION, EXTRA-UTERINE FCETATION, AND MISSED LABOR. 

PAGE 

Plural Births, their frequency: Relative frequency in different Countries; 
Causes, etc. — Super-foetation and Super-fecundation — Nature — Explanation — 
Objections to admission of such cases — Their possibility admitted — Extra- 
Uterine Pregnancy — Classification — Causes — Tubal Pregnancies — Changes in the 
Fallopian Tubes — Condition of Uterus — Progress and Termination — Diagnosis 
— Treatment — Abdominal Pregnancy : Description ; Diagnosis ; Treatment — 
Missed Labor: its Symptoms, Causes, and Treatment 157 



CHAPTER VII. 



THE DISEASES OF PREGNANCY. 



Some only Sympathetic, others Mechanical or Complex in their Origin — Derange- 
ments of the Digestive Organs : Excessive Nausea and Vomiting ; Diarrhoea ; 
Constipation ; Hemorrhoids ; Ptyalism ; Toothache and Caries of Teeth ; Affec- 
tions of Respiratory Organs ; Dyspnoea, etc. — Palpitation — Syncope — Anaemia 
and Chlorosis — Albuminuria 183 



CHAPTER VIII. 

THE DISEASES OF PREGNANCY {continued). 

Disorders of the Nervous System : Insomnia ; Headaches and Neuralgia ; Paraly- 
sis ; Chorea ; Disorders of the Urinary Organs ; Retention of Urine ; Irritability 
of the Bladder ; Incontinence of Urine ; Phosphatic Deposits ; Leucorrhoea ; 
Effects of Pressure ; Laceration of Veins ; Displacements of the Gravid Uterus ; 
Prolapse, Anteversion, Retroversion — Diseases coexisting with Pregnancy ; 
Eruptive Fevers ; Smallpox, Measles, Scarlet Fever, Continued Fever ; Phthisis ; 
Cardiac Disease ; Syphilis ; Icterus ; Carcinoma ; Pregnancy complicated with 
Ovarian and Fibroid Tumors 196 

CHAPTER IX. 

PATHOLOGY OF THE DECIDUA AND OVUM. 

Pathology of the Decidua — Hydrorrhea Gravidarum — Pathology of the Chorion ; 
Vesicular Degeneration, Myxoma Fibrosum — Pathology of the Placenta : Blood 
Extravasations, Fatty Degeneration, etc. — Pathology of the Umbilical Cord — 
Pathology of the Amnion, Hydramnios ; Deficiency of Liquor Amnii, etc. — 
Pathology of the Foetus : Blood Diseases transmitted through the Mother, Small- 
pox, Measles, and Scarlet Fever, Intermittent Fevers, Lead-poisoning, Syphilis, 
— Inflammatory Diseases — Dropsies — Tumors — Wounds and Injuries of the 
Foetus — Intrauterine Amputations — Death of the Foetus 212 



XIV CONTENTS. 

CHAPTER X. 

ABORTION AND PREMATURE LABOR. 

PAOE 

Importance and Frequency — Definition and Classification — Frequency — Recur- 
rence — Causes — Causes Referable to Foetus — Changes in a Dead Ovum retained 
in Utero — Extravasations of Blood — Moles, etc. — Causes depending on Maternal 
State — Syphilis : Causes acting through Nervous System, Physical Causes, etc. 
— Causes depending on Morbid States of Uterus — Symptoms — Preventive Treat- 
ment — Prophylactic Treatment — Treatment when Abortion is inevitable — After- 
Treatment 229 



PAET III 

LABOR. 



CHAPTER I. 

THE PHENOMENA OF LABOR. 

Causes of Labor — Mode in which the Expulsion of the Child is effected — The 
Uterine contraction — Mode in which the Dilatation of the Cervix is effected — 
Rupture of the Membranes — Character and source of Pains during Labor — 
Effect of Pains on Mother and Foetus — Division of Labor into Stages — Prepara- 
tory Stage — False Pains — First Stage — Second Stage — Third Stage — Mode in 
which the Placenta is expelled — Duration of Labor 242 

CHAPTER II. 

MECHANISM OF DELIVERY IN HEAD PRESENTATIONS. 

Importance of Subject — Frequency of Head Presentations — The different positions 
of the Head — First Position — Division of Mechanical Movements into Stages — 
Flexion — Rotation — Extension — External Rotation — Second Position — Third 
Position — Fourth Position — Caput Succedaneum — Alteration in shape of Head 
from moulding 255 

CHAPTER III. 

MANAGEMENT OF NATURAL LABOR. 

Preparatory Treatment — Dress of Patient during Pregnancy — The Obstetric Bag 
— Duties on first visiting Patient — False Pains — Tbeir Character and Treatment 
— Vaginal Examination — The Position of Patient — Artificial Rupture of Mem- 
branes — Treatment of Propulsive Stage — Relaxation of the Perineum — Treat- 
ment of Lacerations — Expulsion of Child — Promotion of Uterine Contraction — 
Ligature of the Cord — Management of the Third Stage of Labor — Application of 
the Binder— After-Treatment 268 



CONTENTS. XV 

CHAPTER IV. 

ANAESTHESIA IN LABOR. 

PAGE 

Agents employed — Chloral: its Object and Mode of administration — Ether — 
Chloroform : its Use, Objections to, and Mode of administration . . . 282 

CHAPTER V. 

PELVIC PRESENTATIONS. 

Frequency — Causes — Prognosis to Mother and Child — Diagnosis by Abdominal 
Palpation and by Vaginal Examination — Differential Diagnosis of Breech, Knee, 
and Feet — Mechanism — Treatment — Management of Impacted Breech Presenta- 
tions 286 

CHAPTER VI. 

PRESENTATIONS OF THE FACE. 

Erroneous Views formerly held on the Subject — Frequency — Mode of Production — 
Diagnosis — Mechanism — Four Positions of the Face — Description of Delivery 
in First Face Position — Mento-Posterior Positions in which Rotation does not 
take place — Prognosis — Treatment . . . . . . . . .297 

CHAPTER VII. 

DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 

Causes of Face to Pubis Delivery — Mode of Treatment — Upward Pressure on 
Forehead — Downward Traction on Occiput — Use of Forceps — Peculiarities of 
Forceps Delivery 307 

CHAPTER VIII. 

PRESENTATIONS OF SHOULDER, ARM, OR TRUNK COMPLEX 

PRESENTATIONS PROLAPSE OF THE FUNIS. 

Position of the Foetus — Division into Dorso-Anterior and Dorso-Posterior Posi — 
tions — Causes — Prognosis and Frequency — Diagnosis — Mode of distinguishing 
Position of Child — Differential Diagnosis of Shoulder, Elbow, and Hand — 
Mechanism — The Two possible Modes of Delivery by the Natural Powers — 
Spontaneous Version — Spontaneous Evolution — Treatment — Complex Presenta- 
tion : Foot or Hand with Head, Hand and Feet together — Dorsal Displacement 
of the Arm — Prolapse of the umbilical Cord — Frequency — Prognosis — Causes — 
Diagnosis — Postural Treatment — Artificial Reposition — Treatment when Repo- 
sition fails ............. 309 

CHAPTER IX. 

PROLONGED AND PECIPITATE LABORS. 

Evil effects of Prolonged Labor — Influence of the Stage of Labor in Protraction — 
Delay in First Stage rarely serious — Temporary Cessation of Pains — Symptoms 






XVI CONTENTS. 

PAGE 

of Protraction in the Second Stage — State of the Uterus in Protracted Labor — 
Cases of Protraction due to Morbid condition of the expulsive powers — Causes of 
Protraction — Treatment — Oxytocic remedies — Ergot of Rye, etc. — Manual Pres- 
sure — Instrumental Delivery — Precipitate Labor — Its Causes and Treatment . 324 

CHAPTER X. 

LABOR OBSTRUCTED BY FAULTY CONDITION OF THE SOFT PARTS. 

Rigidity of the Cervix : its Causes, Effects, and Treatment — Bands and Cicatrices 
in the Vagina — Extreme rigidity of the Perineum — Labor complicated with 
Tumor — Vaginal Cystocele — Calculus — Hernial Protrusions — CEdema of Vulva 
— Haematic Effusions, etc. ........ . . 339 

CHAPTER XL 

DIFFICULT LABOR DEPENDING ON SOME UNUSUAL CONDITION OF 

THE FCETUS. 

Plural Births, Treatment of — Locked Twins — Conjoined Twins — Intra-uterine 
Hydrocephalus : Its Dangers, Diagnosis, and Treatment — Other dropsical Effu- 
sions — Foetal Tumors — Excessive Development of Foetus . . . . .353 

CHAPTER XII. 

DEFORMITIES OF THE PELVIS. 

Classification — Causes of Pelvic Deformity — Rickets and Osteo-malacia — The 
Equally enlarged Pelvis — The Equally contracted Pelvis — The Undeveloped 
Pelvis — Masculine or Funnel-shaped Pelvis — Contraction of Conjugate Diameter 
of the Brim — Figure-of-Eight deformity — Spondylolithesis — Narrowing of the 
Oblique Diameters — Obliquely contracted Pelvis — Kyphotic Pelvis — Robert's 
Pelvis — Deformity from old-standing Hip-joint disease — Deformity from Tumors, 
Fractures, etc. — Effects of Contracted Pelvis on Labor — Risks to the Mother and 
Child — Mechanism of Delivery in Head Presentation ; a, in Contracted Brim ; 
b, in Generally contracted Pelvis — Diagnosis — External Measurements — Internal 
Measurements — Mode of estimating the Conjugate diameter of the brim — Mode 
of Diagnosing the Oblique Pelvis — Treatment — The Forceps — Turning — The 
Induction of Premature Labor — Induction of Abortion 366 

CHAPTER XIII. 

HEMORRHAGE BEFORE DELIVERY : PLACENTA PREVIA. 

Definition — Causes — Symptoms — Sources and Causes of Hemorrhage — Prognosis — 
Treatment 3S8 

CHAPTER XIV. 

HEMORRHAGE FROM SEPARATION OF A NORMALLY SITUATED PLACENTA. 

Causes and Pathology — Symptoms and Diagnosis — Prognosis — Treatment . . 399 



CONTEXTS. XV11 

CHAPTER XV. 

HEMORRHAGE AFTER DELIVERY. 

PAGB 

Its frequency — Generally a preventable accident — Causes — Nature's method of 
Controlling Hemorrhage — Uterine Contraction — Thrombosis — Secondary Causes 
of Hemorrhage — Irregular Uterine Contraction — Placental Adhesions — Consti- 
tutional Predisposition to Flooding — Symptoms — Preventive treatment — Cura- 
tive treatment — Secondary post-partum Hemorrhage — Its Causes and Treatment 402 

CHAPTER XVI. 

RUPTURE OF THE UTERUS, ETC. 

Its Fatality — Seat of Rupture — Causes, predisposing and exciting — Symptoms — 
Prognosis — Treatment : when the Foetus remains in Utero ; when the Foetus 
has escaped from the Uterus — Recapitulation — Lacerations of the vagina — Vesico 
and Recto-vaginal Fistulae — Their mode of Formation — Treatment . . .419 

CHAPTER XVII. 

INVERSION OF THE UTERUS. 

Division into Acute and Chronic forms — Description — Symptoms — Diagnosis — 
Mode of production — Treatment ......... 429 



PAET IY. 

OBSTETRIC OPERATIONS. 



CHAPTER I. 

INDUCTION OF PREMATURE LABOR. 

History — Objects — May be performed either on account of the Mother or Child — 
Modes of Inducing Labor — Puncture of Membranes — Administration of Oxyto- 
cics — Means acting indirectly on the Uterus — Dilatation of Cervix — Separation 
of Membranes — Vaginal and Uterine douches — Introduction of Flexible Ca- 
theter 435 

CHAPTER II. 

TURNING. 

History — Turning by External Manipulation — Object and Nature of the Opera- 
tion — Cases Suitable for the operation — Statistics and Dangers — Method of 
performance — Cephalic Version — Method of performance — Podalic Version — 
Position of Patient — Administration of Anaesthetics — Period wben the opera- 
tion should be undertaken — Choice of Hand to be used — Turning by Bi-polar 
method — Turning when the Hand is introduced into the Uterus — Turning in 
Abdomino-anterior Positions — Difficult cases of Arm Presentation . . . 442 
2 



XV111 CONTENTS. 

CHAPTER III. 

THE FORCEPS. 

PAGE 

Frequent use of the Forceps in Modern practice — Description of the Instrument — 
The Short Forceps — Its Varieties — The Long Forceps — Suitable to all cases 
alike — Action of the Instrument — Its power as a Tractor, Lever, and Compres- 
sor — Preliminary considerations before operation — Use of Anaesthetics — De- 
scription of the Operation — Low Forceps Operation — High Forceps Operation — 
Possible Dangers of Forceps Delivery — Possible Risks to the Child . . .458 

CHAPTER IV. 

THE VECTIS THE FILLET. 

Nature of the Vectis — Its use as a Lever or Tractor — Cases in which it is appli- 
cable — Its use as a Rectifier of Malpositions — The Fillet — Nature of the Instru- 
ment — Objections to its use 482 

CHAPTER V. 

OPERATIONS INVOLVING THE DESTRUCTION OF THE FCETUS. 

Their Antiquity and History — Division of Subject — Nature of Instruments em- 
ployed — Perforator — Crotchet — Craniotomy Forceps — Cephalotribe — Forceps- 
saw — Ecraseur — Cases requiring Craniotomy — Method of Perforation — Extrac- 
tion of the Head — Comparative merits of Cephalotripsy and Craniotomy — 
Extraction by the Craniotomy Forceps — Extraction of the Body — Embryotomy — 
Decapitation and Evisceration 484 

CHAPTER VI. 

THE CESAREAN SECTION SYMPHYSEOTOMY AND LAPARO-ELYTROTOMY. 

History of the Operation — Statistics — Results to Mother and Child — Causes re- 
quiring the Operation — Post-mortem Caesarean Section — Causes of Death after 
the Caesarean Section — Preliminary Preparations — Description of the Operation 
— Subsequent Management — Substitutes for the Caesarean Section — Symphyse- 
otomy — Laparo-elytrotomy 499 

CHAPTER VII. 

THE TRANSFUSION OF BLOOD. 

History — Nature and Object of the Operation — Use of Blood taken from the Lower 
Animals — Difficulties from Coagulation of Fibrine — Modes of Obviating them — 
Immediate Transfusion — Addition of Chemical Agents to prevent Coagulation — 
Defibrination of the Blood — Statistical Results — Possible Dangers of the Opera- 
tion — Cases suitable for Transfusion — Description of the Operation — Effects of 
Successful Transfusion — Secondary Effects of Transfusion 514 



CONTENTS. XIX 

PAET V. 

THE PUERPERAL STATE. 



CHAPTER I. 

THE PUERPERAL STATE AND ITS MANAGEMENT. 

PAGE 

Importance of Studying the Puerperal State — The Mortality of Childbirth — Alte- 
rations in the Blood after Delivery — Condition after Delivery — Nervous Shock 
— Fall of the Pulse — The Secretions and Excretions — Secretion of Milk — 
Changes in the Uterus after Delivery — The Lochia — The After-pains — Manage- 
ment of Women after Delivery — Treatment of Severe After-pains — Diet and 
Regimen .............. 523 

CHAPTER II. 

MANAGEMENT OF THE INFANT, LACTATION, ETC. 

Commencement of Respiration after the Birth of the Child — Apparent Death of 
the new-born Child — Its Treatment — Washing and Dressing the Child — Ap- 
plication of the Child to the Breast — The Colostrum and its Properties — Secre- 
tion of Milk — Importance of Nursing — Selection of a Wet-nurse — Management 
of Lactation — Diet and Regimen of Nursing Women — Period of Weaning — 
Disorders of Lactation — Means of Arresting the Secretion of Milk — Defective 
Secretion of Milk — Depressed Nipples— Fissures and Excoriations of the Nipples 
— Excessive Flow of Milk — Mammary Abscess — Hand-feeding — Causes of Mor- 
tality in Hand-feeding — Various kinds of Milk — Method of Hand-feeding . 533 

CHAPTER III. 

PUERPERAL ECLAMPSIA. 

Its Doubtful Etiology — Premonitory Symptoms — Symptoms of the attack — Con- 
dition between the Attacks — Relation of the attacks to Labor — Results to 
Mother and Child — Pathology — Treatment — Obstetric Management . . .550 

CHAPTER IV. 

PUERPERAL INSANITY. 

Classification — Proportion of Various forms — Insanity of Pregnancy — Predispos- 
ing Causes — Period of Pregnancy at which it occurs — Type of Insanity — 
Prognosis — Transient Mania during Delivery — Puerperal Insanity (Proper) — 
Type of Insanity — Causes— Theory of its dependence on a Morbid State of the 
Blood — Objections to the theory — Prognosis — Post-mortem signs — Duration — 
Insanity of Lactation — Type — Symptoms — Of Mania — Of Melancholia — Treat- 
ment — Question of Removal to Asylum — Treatment during Convalescence . 559 



XX CONTENTS. 

CHAPTER V. 

PUERPERAL SEPTICEMIA. 

PAGE 

Differences of opinion — Confusion from this cause — Modern view of this Disease — 
History — Its Mortality in Lying-in Hospitals — Numerous Theories as to its 
Nature — Theory of Local Origin — Theory of an Essential Zymotic Fever — 
Theory of its identity with Surgical Septicaemia — Nature of this view — 
Channels through which Septic Matter may be absorbed — Character and Origin 
of Septic Matter often obscure — Division into Auto-genetic and Hetero-genetic 
cases — Sources of Self-infection — Sources of Hetero-genetic Infection — Influence 
of Cadaveric Poison — Infection from Erysipelas — Infection from other Zymotic 
Diseases — Contagion from other Puerperal Patients — Mode in which the Poison 
may be conveyed to the Patient — Conduct of the Practitioner in relation to the 
Disease — Nature of the Septic Poison — Local changes resulting from the ab- 
sorption of Septic Material — Channels through which Systemic Infection is 
produced — Pathological Phenomena observed after general Blood Infection — 
Four principal Types of Pathological Change — Intense cases without marked 
Post-mortem Signs — Cases characterized by Inflammation of the Serous Mem- 
branes — Cases characterized by the impaction of Infected Emboli, and Secondary 
Inflammation and Abscess — Description of the Disease — Duration — Varieties of 
Symptoms in different cases — Symptoms of Local Complications — Treatment . 570 

CHAPTER VI. 

PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 

Puerperal Thrombosis and its Results — Conditions which favor Thrombosis — Con- 
ditions which favor Coagulation in the Puerperal State — Distinction between 
Thrombosis and Embolism — Is primary Thrombosis of the Pulmonary Arteries 
possible? — History — Symptoms of Pulmonary Obstruction — Is recovery pos- 
sible ? — Causes of Death — Post-mortem appearances — Treatment . . . 594 

CHAPTER VII. 

PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 
Causes — Symptoms — Treatment 605 

CHAPTER VIII. 

OTHER CAUSES OF SUDDEN DEATH DURING- LABOR AND THE PUERPERAL 

STATE. 

Organic and Functional causes — Idiopathic Asphyxia — Pulmonary Apoplexy — 
Cerebral Apoplexy — Syncope — Shock and Exhaustion — Entrance of Air into 
the Veins 607 

CHAPTER IX. 

PERIPHERAL VENOUS THROMBOSIS (SYN. : CRURAL PHLEBITIS PHLEGMASIA 

DOLENS ANASARCA SEROSA (EDEMA LACTEUM WHITE LEG, ETC.). 

Nature — Symptoms — History and Pathology — Anatomical form of the Thrombi 
in the Veins — Detachment of Emboli — Treatment ...... 609 



CONTEXTS. XXI 

CHAPTER X. 

PELVIC CELLULITIS AND PELVIC PERITONITIS. 

PAGE 

Two Forms of Disease — Variety of Nomenclature — Importance of Differential 
Diagnosis — Etiology — Connection with Septicaemia — Seat of Inflammation — 
Relative Frequency of the two forms of Disease — Symptomatology — Results of 
Physical Examination — Terminations — Prognosis — Treatment . . .616 



[APPENDIX. 

The Intravenous Injection of Fresh Milk, as an Improved Substitute for the 
Transfusion of Blood 625] 

INDEX 629 



2* 






ILLUSTRATIONS 



Section of a Frozen Body in the last months of Pregnancy (after Branne) . Illus- 
trating the Relations of the Uterus to the surrounding Parts, and the attitude 
of the Foetus, which is lying in the second Cranial Position . . Plate I 

Section of a Frozen Body at the termination of the first stage of Labor (after 
Braune) . The bag of membranes is still unbroken, the cervix is fully dilated, 
and the head (in the second position) is in the pelvic cavity . . Plate II. 

FIG. PAGE 

1. Os innominatum ............ 26 

2. Sacrum and Coccyx 27 

3. Section of Pelvis and heads of Thigh-bones, showing the Suspensory Action 

of the Sacro-iliac Ligaments. (After Wood.) ...... 29 

4. Outlet of Pelvis 32 

5. The Female Pelvis . ,32 

6. The Male Pelvis 33 

7. Brim of Pelvis, showing Antero-posterior, Oblique, and Conjugate Diameters 34 

8. Transverse section of Pelvis, showing the Diameters ..... 34 

9. Planes of the Pelvis, with Horizon 36 

10. Axes of the Pelvis 37 

11. Representing general Axis of the Parturient Canal, including the Uterine 

Cavity and Soft Parts 38 

12. Side view of Pelvis 38 

13. Pelvis of a Child 39 

14. Vascular Supply of Vulva. (After Kobelt.) 45 

15. Longitudinal section of Body, showing Relation of Generative Organs . 46 

16. Transverse section of Body, showing Relations of the Fundus Uteri . . 48 

17. Transverse section of Uterus . . . . . ... . .49 

18. Uterus and Appendages in an Infant . 49 

19. Portion of Interior of Cervix. (Enlarged nine diameters.) .... 51 

20. Muscular Fibres of unimpregnated Uterus. (After Farre.) ... 52 

21. Developed Muscular Fibres from the Gravid Uterus. (After Wagner.) . 52 

22. Lining Membrane of Uterus, showing network of Capillaries and Orifices of 

Uterine Glands. (After Farre.) ........ 54 

23. The Course of the Glands in the fully developed Mucous Membrane of the 

Uterus. (After Williams.) . ....... 54 

24. Villi of Os I'teri stripped of Epithelium 55 

25. Villi of Uterus, covered with Pavement Epithelium and containing Looped 

Vessels. (After Tyler Smith and Hassall.) 66 

26. Bifid Uterus. (After Farre.) 58 

27. Adult Parovarium, Ovary, and Fallopian Tube. (After Kobelt.) . . 59 
28 Posterior view of Muscular and Vascular arrangements. (After Rouget.) . 60 
29. Fallopian Tube laid open. (After Richard.) 62 



XXIV ILLUSTRATIONS. 

FIG. PAGE 

30. Ovary enlarged under Menstrual Nisus 64 

31. Longitudinal Section of Adult Ovary. (After Farre.) ..... 65 

32. Section through the cortical part of the Ovary. (After Turner.) . . 66 

33. Vertical Section through the Ovary of the Human Foetus. (After Foulis.) 66 

34. Diagramatic Section of Graafian Follicle 67 

35. Bulb of Ovary 69 

36. Mammary Gland 70 

37. Section of Ovary, Showing Corpus Luteum three weeks after Menstruation. 

(After Dalton.) 74 

38. Corpus Luteum at the fourth month of Pregnancy. (After Dalton.) . . 75 

39. Corpus Luteum of Pregnancy at Term. (After Dalton.) .... 75 

40. Sperm Cells and Nuclei . . . . 84 

41. Ovum of Rabbits containing Spermatozoa 86 

42. Formation of the "Polar Globule" 87 

43. Segmentation of the Yelk 88 

44. Formation of the Blastodermic Membrane. (After Joulin.) ... 89 

45. Aborted Ovum (of about forty days), showing the Triangular Shape of the 

Decidua (which is laid open), and the Aperture of the Fallopian Tube. 

(After Coste.) 91 

46. \ 

47. > Formation of the Decidua. (After Dalton.) ...... 91 

48. ) 

49. An Ovum removed from the Uterus, and part of the Decidua Vera cut away. 

(After Coste.) 92 

50. Diagram of Area Germinativa, showing the primitive trace and Area Pel- 

lucida 94 

51. Development of the Amnion . . . . . . . . .95 

52. Development of the Umbilical Vesicle and Amnion . . . . .96 

53. An Embryo of about twenty-five days laid open. (After Coste.) . . 96 

54. Development of the Chorion 97 

55. Placental Villus, greatly magnified. (After Joulin.) 102 

56. Terminal Villus of Foetal Tuft, minutely Injected. (After Farre.) . . 103 

57. Diagram representing a Vertical Section of the Placenta. (After Dalton.) . 103 

58. Diagram illustrating the Mode in which a Placental Villus derives a Cover- 

ing from the Vascular System of the Mother. (After Priestley.) . . 104 

59. The Extremity of a Placental Villus. (After Goodsir.) . . . .104 

60. Anterior and Posterior Fontanelles . . . . . . . .111 

61. Bi-parietal diameter, Sagittal and Lambdoidal Sutures, with Posterior Fon- 

tanelle ............. Ill 

62. Diameters of the Foetal Skull Ill 

63. Mode of ascertaining the Position of the Foetus by Palpation . . . 114 

64. Diagram illustrating the Effect of Gravity on the Foetus. (After Duncan.) . 115 

65. Illustrating the greater Mobility of the Foetus and the larger relative amount 

of Liquor Amnii in Early Pregnancy. (After Duncan.) . . . 116 

66. Diagram of Foetal Heart. (After Dalton.) 119 

67. Diagram of Heart of Infant. (After Dalton.) ...... 121 

68. Size of Uterus at various Periods of Pregnancy ...... 124 

69. \ 

70. I Supposed Shortening of the Cervix at the third, sixth, seventh, and nine 

71. j months of Pregnancy, as figured in Obstetric works .... 126 

72. J 



ILLUSTRATIONS. XXV 

FIff. PAGE 

73. Cervix of a Woman Dying in the eighth Month of Pregnancy. (After 

Duncan.) 127 

74. Appearance of the Areola in Pregnancy ....... 137 

75. Illustrating the Cavity between the Decidua Vera and the Decidua Reflexa 

during the early Months of Pregnancy. (After Coste.) .... 163 

76. Tubal Pregnancy, with the Corpus Luteum in the Ovary of the opposite 

side 166 

77. Tubal Pregnancy. (From a specimen in the Museum of King's College.) . 167 

78. Extra-uterine Pregnancy at term of the Tubo-Ovarian Variety. (After 

a case of Dr. A. Sibley Campbell's.) 169 

79. Uterus and Foetus in a case of Abdominal Pregnancy .... 175 

80. Lithopsedion. (From a preparation in the Museum of the Royal College of 

Surgeons.) . ........... 176 

81. Contests of the Cyst in Dr. Oldham's case of Missed Labor . . . 182 

82. Hypertrophied Decidua laid open, with the Ovum attached to its Fundal 

Portion. (After Duncan.) 213 

83. Imperfectly developed Decidua Vera, with the Ovum. (After Duncan.) . 214 

84. Hydatiform Degeneration of the Chorion . . . . . . .215 

85. Double Placenta, with Single Cord 219 

86. Fatty Degeneration of the Placenta 220 

87. Knots in the Umbilical Cord 221 

88. Intra-uterine Amputation of both Arms and Legs 226 

89. An apoplectic Ovum, with Blood effused in masses under the Foetal Surface 

of the Membranes 231 

90. Blighted Ovum, with Fleshy Degeneration of the Membranes . . . 232 

91. Mode in which the Placenta is Naturally Expelled. (After Duncan.) . 253 

92. Attitude of Child in first position. (After Hodge.) 258 

93. First Position : Movement of Flexion 259 

94. First Position : Occiput in Cavity of Pelvis. (After Hodge.) . . .260 

95. First Position: Occiput at Outlet of Pelvis. (After Hodge.) . . .261 

96. First Position : Head Delivered. (After Hodge.) 263 

97. External Rotation of Head in first position. (After Hodge.) . . . 263 

98. Third Position of Occiput at Brim of Pelvis 264 

99. Fourth Position of Occiput at Pelvic Brim 267 

100. Examination during the First Stage of Labor 272 

101. Mode of effecting Relaxation of the Perineum 276 

102. Usual Method of Removing the Placenta by Traction on the Cord . . 279 

103. Illustrating Expression of the Placenta 280 

104. First, or left Sacro-cotyloid position of the Breech 290 

105. Passage of the Shoulders and partial Rotation of the Thorax . . .291 

106. Descent of the Head 292 

107. Second position in Face Presentation 300 

108. Rotation Forwards of Chin 302 

109. Passage of the Head through the External Parts in Face Presentation . 302 

110. Illustrating the position of the Head when Forward Rotation of the Chin 

does not take place 303 

111. Dorso-anterior Presentation of the Arm 311 

112. Dorso-posterior Presentation of the Arm 311 

113. Commencing Spontaneous Evolution 316 

114. Spontaneous Evolution further Advanced 316 

115. Dorsal Displacement of the Arm 318 



XXVI ILLUSTRATIONS. 

FI«. PAGE 

116. Dorsal Displacement of the Arm in Footling Presentations. (After Barnes.) 319 

117. Prolapse of the Umbilical Cord 320 

118. Postural Treatment of Prolapse of the Cord 322 

119. Braun's Apparatus for Replacing the Cord . . . . . . 323 

120. Labor complicated by Ovarian Tumor ....... 345 

121. Twin Pregnancy, Breech and Head presenting ...... 353 

122. Head Locking, both Children presenting Head first. (After Barnes) . 355 

123. Head Locking, first Child coming Feet first ; Impaction of Heads from 

wedging in Brim. (After Barnes) ....*... 357 

124. Labor impeded by Hydrocephalus 362 

125. Adult Pelvis retaining its Infantile Type . . . . . . .369 

126. Rickety Pelvis, with backward depression of Symphysis Pubis . . 371 

127. Flatness of Sacrum, with narrowing of Pelvic Cavity .... 371 

128. Pelvis deformed by Spondylolithesis. (After Kilian) .... 371 

129. Osteo-malacic Pelvis 373 

130. Extreme degree of Osteo-malacic Deformity ....... 373 

131. Obliquely Contracted Pelvis. (After Duncan) 374 

132. Robert's, or double obliquely Contracted Pelvis ..... 375 

133. Bony Growth from Sacrum obstructing the Pelvic Cavity .... 375 

134. Greenhalgh's Pelvimeter . . . ■ 380 

135. Section of Foetal Cranium, showing its Conical Form .... 384 

136. Showing the greater Breadth of the biparietal Diameter of the Foetal Cra- 

nium. (After Simpson) 384 

137. Showing the greater Space for the biparietal Diameter in certain Cases of 

Deformity. (After Simpson) 384 

138. Irregular Contraction of the Uterus, with Encystment of the Placenta . 406 

139. Partial Inversion of the Fundus 430 

140. Illustrating the Commencement of Inversion at the Cervix. (After Duncan) 432 

141. Barnes's Bag for Dilating the Cervix 439 

142. First Stage of Bi-polar Version 449 

143. Second Stage of Bi-polar Version ........ 450 

144. Third Stage of Bi-polar Version 450 

145. Fourth Stage of Bi-polar Version 451 

146. Seizure of the Feet when the Hand is introduced into the Uterus . . 453 

147. Drawing down of the Feet and Completion of Version .... 454 

148. Showing the Completion of Version. (After Barnes) .... 455 

149. Showing the Use of the Right Hand in Abdomino-anterior positions . . 456 

150. Denman's Short Forceps 459 

151. Zeigler's Forceps 460 

152. Simpson's Forceps ........... 461 

153. Tarnier's Forceps 462 

154. Position of Patient for Forceps Delivery, and Mode of Introducing the 

Lower Blade 466 

155. Introduction of the Upper Blade 468 

156. Forceps in position; Traction in the Axis of the Brim, downwards and 

backwards ............ 469 

157. Last Stage of Extraction ; the Handles of the Forceps turned upwards 

towards the Mother's Abdomen ........ 470 

[158. Hodge Forceps 474] 

[159. Wallace " 475] 

[160. Davis " 475] 



ILLUSTRATIONS. XXV11 

FIG. PAGE 

[161. Elliot Forceps 476] 

[162. Sawyer " - . 477] 

[163. Application of Forceps at Inferior Strait 478] 

[164. Application of Forceps in the Head at Superior Strait, the left Blade held 

in place by an Assistant 480] 

[165. Direction of Forceps as Head is being Delivered 481] 

166. Vectis with Hinged Handle 483 

167. Wilmot's Fillet 484 

168. -j 

169. > Various forms of Perforators . . 486 

170. ) 

171 & 172. Crotchets . . .487 

173. Craniotomy Forceps 488 

174. Simpson's Cranioclast .......... 488 

175. Hick's Cephalotribe 489 

176. Perforation of the Skull 492 

177. Foetal Head crushed by the Cephalotribe 495 

[178. Straight Craniotomy Forceps 496] 

[179. Curved " " 496] 

180. Method of Transfusion by Aveling's Apparatus 521 

181. Section of a Uterine Sinus from the Placental Site nine weeks after delivery. 

(After Williams) .528 

182. Haye's Tube for Intra-uterine Injections ....... 588 



PLATE I 




Os Pubis 



Bladder. 



Clitoris 



Portio 
Vaginalis 



Vagina. 



Section of a Frozen Body in the last month of Pregnancy (after Brau.ne), illustrating the Kelations of the 
Uterus to the surrounding parts, and tlio Attitude of the Foetus, which is lying in the Second Cranial 
Position. 



PLATE II 




Liquor Amnii 



;tiou of a Frozen Body at the Termination of the First Stage of Labor (after Brauuo). The Bag of Mem- 
branes is still unbroken, the Cervix is fully dilated, and the Head (in the second position) is in the Pel vie 






THE SCIENCE AND PRACTICE 



MIDWIFERY. 



PART I. 



ANATOMY AND PHYSIOLOGY OF THE ORGANS CONCERNED 
IN PARTURITION. 



CHAPTEE I. 

ANATOMY OF THE PELVIS. 

The pelvis is the bom* basin situated between the trunk and the 
lower extremities. To the obstetrician its study is of paramount 
importance, for it not only contains, in the unimpregnated state, all 
the organs connected with the function of reproduction, but through 
its cavity the foetus has to pass in the process of parturition. An 
accurate knowledge, therefore, of its anatomical formation may be 
said to be the very alphabet of obstetrics, without which no one can 
practise midwifery, either with satisfaction to himself, or safety to 
his patient. 

In a treatise on obstetrics, however, any detailed account of the 
purely descriptive anatomy of the pelvis would be out of place. A 
knowledge of that must be taken for granted, and it is only necessary 
to refer to those points which have a more or less direct bearing on 
the study of its obstetrical relations. 

The pelvis is formed of four bones. On either side are the ossa 
innominata, joined together by the sacrum; to the inferior extremity 
of the sacrum is attached the coccyx, which is, in fact, its continuation. 

The os innominatum (Fig. 1) is an irregularly shaped bone origi- 
nally formed of three distinct portions, the ilium, the ischium, and 
the pubes, which remain separated from each other up to and beyond 
the period of puberty. They are united at the acetabulum by a 
Y-shaped cartilaginous junction, which does not, as a rale, become 
ossified until about the twentieth year. The consequence is that the 
pelvis, during the period of growth, is subject to the action of various 
mechanical influences to a far greater extent than in adult life; and 
3 



26 



ORGANS CONCERNED IN PARTURITION. 



these, as we shall presently see, have an important effect in deter- 
mining the form of the bones. The external surface and borders of 
the os innominatum are chiefly of obstetric interest from giving 
attachment to muscles, many of which have an important accessory 
influence on parturition, such as the muscles forming the abdominal 
wall, which are attached to its crest, and those closing its outlet and 



Fig. 1. 




Os InDominatuin. 

forming the perineum, which are attached to the tuberosity of the 
ischium. On the anterior and posterior extremities of the crest of 
the ilium are two prominences (the anterior and posterior spinous 
processes) which are points from which certain measurements are 
sometimes taken. The internal surface of the upper fan-shaped 
portion of the os innominatum gives attachment to the iliacus muscle, 
and contributes to the support of the abdominal contents ; along with 
its fellow of the opposite side it forms the false pelvis. The false is 
separated from the true pelvis by the ilio-pectineal line, which, with 
the upper margin of the sacrum, forms the brim of the pelvis. This 
is of especial obstetric importance, as it is the first part of the pelvic 
cavity through which the child passes, and that in which osseous 
deformities are most often met with. At one portion of the ilio- 
pectineal line, corresponding with the junction of the ilium and pubes, 
is situated a prominence, which is known as the ilio-pectineal eminence. 

Internal Surface. — The internal smooth surface of the innominate 
bone below the linea ilio-pectinea forms the greater portion of the 
pelvis proper. In front, with the corresponding portions of the 
opposite bone, it forms the arch of the pubes, under which the head 
of the child passes in labor. 

Behind this we observe the oval obturator foramen, and below that 
the tuberosity and spine of the ischium, the latter separating the great 
and lesser sciatic notches, and giving attachment to ligaments of im- 
portance. The rough articulating surface posteriorly, by which the 
junction with the sacrum is effected, may be noted, and above this 



ANATOMY OF THE PELVIS. 



27 



Fig. 2. 




Sacrum and Coccyx. 



the prominence to which the powerful ligaments joining the sacrum 
and os innominatum are attached. 

The sacrum (Fig. 2) is a triangular and somewhat spongy bone, 
forming the continuation of the spinal column, and binding together 
the ossa innominata. It is originally 
composed of five separate portions, anal- 
ogous to the vertebrae, which ossify and 
unite about the period of puberty, leaving 
on its internal surface four prominent 
ridges at the points of junction. The 
upper of these is sometimes so well 
marked as to be mistaken, on vaginal 
examination, for the promontory of the 
sacrum itself. 

The base of the sacrum is about -ij 
inches in width, and its sides rapidly ap- 
proximate until they nearly meet at its 
apex, giving the whole bone a triangular 
or wedge shape. The anterior and pos- 
terior surfaces also approximate in the 
same way, so that the bone is much 
thicker at the base than at the apex. 
The sacrum, in the erect position of the 
body, is directed from above downwards and from before backwards. 
At its upper edge it is joined, the lumbo-sacral cartilage intervening, 
with the fifth lumbar vertebra. The point of junction, called the 
promontory of the sacrum, is of great importance, as on its undue 
projection many deformities of the brim of the pelvis depend. The 
anterior surface of the bone is concave, and forms the curve of the 
sacrum; more marked in some cases than in others. There is also 
more or less concavity from side to side. On it we observe four 
apertures on each side, the intervertebral foramina, giving exit to 
nerves. The posterior surface is convex, rough and irregular for the 
attachment of ligaments and muscles, and showing a ridge of vertical 
prominences, corresponding to the spinous processes of the vertebrae. 

Mechanical Relations of the Sacrum. — The sacrum is generally de- 
scribed as forming a keystone to the arch constituted by the pelvic 
bones, and transmitting the weight of the body, in consequence of its 
wedge-like shape, in a direction which tends to thrust it downwards 
and backwards, as if separating the ossa innominata. Dr. Duncan, 1 
however, has shown, from a very careful consideration of its 
mechanical relations, that it should rather be regarded as a strong 
transverse beam, curved on its anterior surface, the extremities of 
which are in contact with the corresponding articular surfaces of the 
ossa innominata. The weight of the body is thus transmitted to the 
innominate bones, and through them to the acetabula and the femurs. 
(Fig. 3.) There counter-pressure is applied, and the result is, as we 
shall subsequently see, an important modifying influence on the 
development and shape of the pelvis. 



Researches in Obstetrics, p. G7. 



28 ORGANS CONCERNED IN PARTURITION. 

The coccyx (Fig. 2) is composed of four small separate bones, which 
eventually unite into one, but not until late in life. The uppermost 
of these articulates with the apex of the sacrum. On its posterior 
surface are two small cornua, which unite with corresponding points 
at the tip of the sacrum. The bones of the coccyx taper to a point. 
To it are attached various muscles which have the effect of imparting 
considerable mobility. During labor, also, it yields to the mechanical 
pressure of the presenting part, so as to increase the antero-posterior 
diameter of the pelvic outlet to the extent of an inch or more. 

Ossification of Coccyx. — If, through disease or accident, as sometimes 
happens, the articular cartilages of the coccyx become prematurely 
ossified, the enlargement of the pelvic outlet during labor may be 
prevented, and considerable difficulty may thus arise. This is most 
apt to happen in aged primiparse, or in women who have followed 
sedentary occupations ; and not infrequently, under such circitm- 
stances, the bone fractures under the pressure to which it is subjected 
by the presenting part. 

Pelvic Articulations. — -The pelvic bones are firmly joined together 
by various articulations and ligaments. The latter are arranged so 
as to complete the canal through which the foetus has to pass, and 
which is in great part formed by the bones. On its internal surface, 
where the absence of obstruction is of importance, they are every- 
where smooth; while externally, where strength is the desideratum, 
they are arranged in larger masses, so as to unite the bones firmly 
together. The pelvic articulations have been generally described as 
symphyses or amphiarthrodia, ,a term which is properly applied to 
two articulating surfaces, united by fibrous tissue in such a way as 
to prevent any sliding motion. It is certain, however, that this is 
not the case with the joints of the female pelvis during pregnancy 
and parturition. Lenoir found that in 22 females, between the ages 
of 18 and 35, there was a distinct sliding motion. Therefore, the 
pelvic articulations are, strictly speaking, to be considered examples 
of the class of joints termed arthrodia. 

Lumbosacral Joint. — The last lumbar vertebra is united to the 
sacrum by ligamentous union similar to that which joins the vertebrae 
to each other. The intervening fibro- cartilage forms a disk, which 
is thicker in front than behind, and this, in connection with a similar 
peculiarity of the fifth lumbar vertebra, tends to increase the sloped 
position of the sacrum, and the angle which it forms with the verte- 
bral column. It constitutes the most prominent portion of the pro- 
montory of the sacrum, and is the part on which the finger generally 
impinges in vaginal examinations. The anterior common vertebral 
ligament passes over the surface of the joints, and we also find the 
ligamenta sub-flava and the inter-spinous ligaments, as in the other 
vertebrae. The articular processes are joined together by a fibrous 
capsule, and there is also a peculiar ligament, the lumbo-sacral, 
extending from the transverse process of the vertebra on each side, 
and attaching itself to the sides of the sacrum and the sacro-iliac 
synchondrosis. 

Ligaments of Coccyx. — The sacrum is joined to the coccyx, and, in 



ANATOMY OF THE PELVIS 



29 



some cases at least, the separate bones of the coccyx to each other, 
by small cartilaginous disks like that connecting the sacrum with 
the last lumbar vertebra. They are farther united by anterior and 
posterior common ligaments, the latter being much the thicker and 
more marked. In the adult female a synovial membrane is found 
between the sacrum and coccyx, and it is supposed that this is formed 
under the influence of the movements of the bones on each other. 

Sacro-iliac Synchondrosis. — The opposing articular surfaces of the 
sacrum and ilium are each covered by cartilages, that of the sacrum 
being the thickest. These ' are firmly united, but, in the female, 
according to Mr. Wood, 1 they are always more or less separated by 
an intervening synovial membrane. Posterior to these cartilaginous 
convex surfaces there are strong interosseous ligaments, passing 
directly from bone to bone, filling up the interspace between them, 
and uniting them firmly. There are also accessory ligaments, such 
as the superior and anterior sacro iliac, which are of secondary con- 
sequence. The posterior sacro-iliac ligaments, however, are of great 
obstetric importance. They are the very strong attachments which 
unite the rough surfaces on the posterior iliac tuberosities to the 
posterior and lateral surfaces of the sacrum. They pass obliquely 

Fig. 3. 




Section of Pelvis and Heads of Thigh-bones, showing the Suspensory Action of the Sacro-iliac ■ 
Ligaments. (After Wood.) 

downwards from the former points, and suspend, as it were, the 
sacrum from them. According to Duncan, the sacrum has nothing 
to prevent its being depressed by the weight of the body but these 



Todd's Cyclopaedia of Anatomy and Physiology, article "Pelvis," p. 123. 



30 ORGANS CONCERNED IN PARTURITION. 

ligaments, and it is mainly through, them that the weight of the body 
is transmitted to the sacro-cot)doid beams and the heads of the femur. 

Sacro-sciatic Ligaments. — The sacro-sciatic ligaments are instru- 
mental in completing the canal of the pelvis. The greater sacro- 
sciatic ligament is attached by a broad base to the posterior spine of 
the ilium, and to the posterior surfaces of the ilium and coccyx. Its 
fibres unite into a thick cord, cross each other in an X-like manner, 
and again expand at their insertion into the tuberosity of the ischium. 
The lesser sacro-sciatic ligament is also attached with the former to 
the back parts of the sacrum and coccyx, its fibres passing to their 
much narrower insertion at the spine of the ischium, and converting 
the sacro-sciatic notch into a complete foramen. 

Obturator Mem.br ane. — The obturator membrane is the fibrous 
aponeurosis that closes the large obturator foramen. Joulin 1 supposes 
that, along with the sacro-sciatic ligaments, it may, by yielding some- 
what to the pressure of the foetal head, tend to prevent the contusion 
to which the soft parts would be subjected if they were compressed 
between two entirely osseous surfaces. 

Symphysis Pubis. — -The junction of the pubic bones in front is 
effected by means of two oval plates of fibro-cartilage, attached to 
each articular surface by nipple-shaped projections, which fit into 
corresponding depressions in the bones. There is a greater separa- 
tion between the bones in front than behind, where the numerous 
fibres of the cartilaginous plates intersect, and unite the bones firmly 
together. At the upper and back part of the articulation there is 
an interspace between the cartilages, which is lined by a delicate 
membrane. In pregnancy this space often increases in size, so as 
to extend even to the front of the joint. The juncture is further 
strengthened by four ligaments, the anterior, the posterior, the supe- 
rior, and the sub-pubic. Of these, the last is the largest, connecting 
together the pubic bones and forming the upper boundary of the 
pubic arch. 

Movements of Pelvic Joints. — The close apposition of the bones of 
the pelvis might not unreasonably lead to the supposition that no 
movement took place between its component parts ; and this is the 
opinion which is even yet held by many anatomists. It is tolerably 
certain, however, that even in the unimpregnated condition there is 
a certain amount of mobility. Thus Zaglas has pointed out 2 that in 
man there is a movement in an antero-posterior direction of the 
sacro-iliac joints, which has the effect, in certain positions of the bod}^ 
of causing the sacrum to project downwards to the extent of about 
a line, thus narrowing the pelvic brim, tilting up the point of the 
bone, and thereby enlarging the outlet of the pelvis. This movement 
seems habitually brought into play in the act of straining during 
defecation. 

Observations in the Lower Animals. — During pregnancy in some of 
the lower animals there is a very marked movement of the pelvic 
articulations, which materially facilitates the process of parturition. 

1 Traite d' Accouchements, p. 11. 

2 Monthly Journal of Med. Science, Sept. 1851. 



ANATOMY OF THE PELVIS. 31 

This, in the case of the guinea-pig and cow, has been specially pointed 
out by Dr. Matthews Duncan. 1 In the former, during labor, the 
pelvic bones separate from each other to the extent of an inch or 
more. In the latter the movements are different, for the sj^mphysis 
pubis is fixed by bony anchylosis, and is immovable; but the sacro- 
iliac joints become swollen during pregnancy, and extensive move- 
ments in an antero-posterior direction take place in them, which 
materially enlarge the pelvic canal during labor. 

Mode in which the Movements are effected. — It is extremely probable 
that similar movements take place in women, both in the symphysis 
pubis and in the sacroiliac joints, although to a less marked extent. 
These are particularly well described by Dr. Duncan. They seem to 
consist chiefly in an elevation and depression of the symphysis pubis, 
either by the ilia moving on the sacrum, or by the sacrum itself 
undergoing a forward movement on an imaginary transverse axis 
passing through it, thus lessening the pelvic brim to the extent of 
one or even two lines, and increasing, at the same time, the diameter 
of the outlet by tilting up the apex of the sacrum. These movements 
are only an exaggeration of those which Zaglas describes as occurring 
normally during defecation. The instinctive positions which the 
parturient woman assumes find an explanation in these observations. 
During the first stage of labor, when the head is passing through the 
brim, she sits, or stands, or walks about, and in these erect positions 
the symphysis pubis is depressed, and the brim of the pelvis enlarged 
to its utmost. As the head advances through the cavity of the 
pelvis, she can no longer maintain her erect position, and she lies 
down and bends her body forward, which has the effect of causing a 
nutatory motion of the sacrum, with corresponding tilting up of its 
apex, and an enlargement of the outlet. 

Alterations in the Pelvic Joints during Pregnancy. — These move- 
ments during parturition are facilitated by the changes which are 
known to take place in the pelvic articulations during pregnancy. 
The ligaments and cartilages become swollen and softened, and the 
synovial membranes existing between the articulating surfaces become 
greatly augmented in size and distended with fluid. These changes 
act by forcing the bones apart, as the swelling of a sponge placed 
between them might do after it had imbibed moisture. The reality 
of these alterations receives a clinical illustration from those cases, 
which are far from uncommon, in which these changes are carried 
to so extreme an extent, that the power of progression is materially 
interfered with for a considerable time after delivery. 

Pelvis as a Whole. — On looking at a pelvis as a Avhole, we are at 
once struck with its division into the true and false pelvis. The 
latter portion (all that is above the brim of the pelvis) is of compara- 
tively little obstetric importance, except in giving attachments to 
the accessory muscles of parturition, and need not be further con- 
sidered. The brim of the pelvis is a heart-shaped opening, bounded 
by the sacrum behind, the linea ilio-pectinea on either side, and the 

1 Researches in Obstetrics, p. 19. 



32 



ORGANS CONCERNED IN PARTURITION. 



symphysis of the pubes in front. All below it forms the cavity, 
which is bounded by the hollow of the sacrum. behind, by the inner 
surfaces of the innominate bones at the sides and in front, and by the 
posterior surface of the symplrysis pubis. It is in this part of the 
pelvis that the changes in direction which the foetal head undergoes 

Fig. 4. 




Outlet of Pelvis. 



in labor are imparted to it. The lower border of this canal, or 
pelvic outlet (Fig. 4), is lozenge-shaped, is bounded by the ischiatic 
tuberosities on either side, the tip of the coccyx behind, and the 
under surface of the pubic symphysis in front. Posteriorly to the 
tuberosities of the ischia the boundaries of the outlet are completed 
by the sacro-sciatic ligaments. 

Differences in the two Sexes. — There is a very marked difference 
between the pelvis in the male and the female, and the peculiarities 
of the latter all tend to facilitate the process of parturition. In the 
female pelvis (Fig. 5) all the bones are lighter in structure, and have 



Fig. 5. 




The Female Pelvis. 



the points for muscular attachments much less developed. The iliac 
bones are more spread out, hence the greater breadth which is ob- 



ANATOMY OF THE PELVIS. S3 

served in the female figure, and the peculiar side-to-side movement 
which all females have in walking. The tuberosities of the ischia 
are lighter in structure and further apart, and the rami of the pubes 
also converge at a much less acute angle. This greater breadth of 
the pubic arch gives one of the most easily appreciable points of 

Fig. 6. 




The Male Pelvis. 



contrast between the male and female pelvis; the pubic arch in the 
female forms an angle of from 90° to 100 3 , while in the male (Fig. 
6) it averages from 70° to 75°. The obturator foramina are more 
triangular in shape. 

The whole cavity of the female pelvis is wider and less funnel- 
shaped than in the male, the symphysis pubis is not so deep, and, as 
the promontory of the sacrum does not project so much, the shape 
of the pelvic brim is more oval than heart-shaped. These differences 
between the male and female pelves are probably due to the presence 
of the female genital organs in the true pelvis, the growth of which 
increases its development in width. In proof of this, Schroeder states 
that in women with congenitally defective internal organs, and in 
women who have had both ovaries removed early in life, the pelvis 
has always more or less of the masculine type. 

Measurements of the Pelvis. — The measurements of the pelvis that 
are of most importance from an obstetric point of view, are taken 
between various points directly opposite to each other, and are known 
as the diameters of the pelvis. Those of the true pelvis are the dia- 
meters which it is especially important to fix in our memories, and 
it is customary to describe three in works on obstetrics — the antero- 
posterior or conjugate, the oblique, and the transverse — although of 
course the measurements may be taken at any opposing points in 
the circumference of the bones. The antero-posterior (sacro-pubic), 
at the brim (Fig. 7), is taken from the upper part of the posterior 
surface of the symphysis pubis to the centre of the promontory of the 
sacrum; in the cavity, from the centre of the symphysis pubis to a 
corresponding point in the body of the third piece of the sacrum : and 






ORGANS CONCERNED IN PARTURITION 
Fig. 7. 




Brim of Pelvis, showing Antero-posterior, Oblique, and Conjugate Diameters. 



Fig. 




Traus verse Section of Pelvis, 
Diameters. 



showing the 



at the outlet (coccy-pubic), from 
the lower border of the symphysis 
pubis to the tip of the coccyx. 
The oblique, at the brim, is taken 
from the sacro-iliac joint on either 
side to a point of the brim corres- 
ponding with the ilio-pectineal em- 
inence (that starting from the right 
sacro-iliac joint being called the 
right oblique, that from the left, the 
oblique); in the cavity a similar 
measurement is made at the same 
level as the conjugate; while at 
the outlet an oblique diameter is 
not usually measured. The trans- 
verse is taken at the brim, from a 
point midway between the sacro- 
iliac joint and the ilio-pectineal 
eminence to a corresponding point 
at the opposite side of the brim; 
in the cavity from points in the 
same plane as the conjugate and 
oblique diameters; and at the 
outlet from the centre of the inner 
border of one ischial tuberosity to 
that of the other. The measure- 
ments given by various writers 
differ considerably, and vary some- 
what in different pelves. Taking 
the average of a large number, 
the following may be given as the 
standard measurements of the 
female pelvis : — 



ANATOMY OF THE PELVIS. 60 



Antero-poste 


rior. 


Oblique. 


Transvev 


in. 




in. 


in. 


4.25 




4.8 


5.2 


4.7 




5.2 


4.75 


5.0 




— 


4.2 



Brim .... 
Cavity .... 
Outlet .... 

It will be observed that the lengths of the corresponding dia- 
meters at different places vary greatly; thus while the transverse 
is longest at the brim, the oblique is longest in the cavity, and the 
anteroposterior at the outlet. It will be subsequently seen that 
this fact is of great practical importance in studying the mecha- 
nism of delivery, for the head in its descent through the pelvis alters 
its position in* such a way as to adapt itself to the largest diameter 
of the pelvis; thus as it passes through the cavity it lies in the 
oblique diameter, and then rotates so as to be expelled in the antero- 
posterior diameter of the outlet. 

Diameters as altered by Soft Parts. — In thinking of these measure- 
ments of the pelvis, it must not be forgotten that they are taken in 
the dried bones, and that they are considerably modified during life 
by the soft parts. This is especially the case at the brim, where the 
projection of the psoas and iliacus muscles lessens the transverse 
diameter about half an inch, while the antero-posterior diameter of 
the brim, and all the diameters of the cavity, are lessened by a 
quarter of an inch. The right oblique diameter of the brim is, even 
in the dried pelvis, found to be, on an average, slightly longer than 
the left ; probably on account of the increased development of the 
right side of the pelvis from the greater use made of the right leg; 
but in addition to this, the left oblique diameter is somewhat lessened 
during life by the presence of the rectum on the left side. The 
advantage gained by the comparatively frequent passage of the head 
through the pelvis in the right oblique diameter is thus explained. 

Other Measurements. — There are one or two other measurements 
of the true pelvis which are sometimes given, but which are of secon- 
cisay importance. One of these, the sacro-cotyloid diameter, is that 
between the promontory of the sacrum and a point immediately 
above the cotyloid cavity, and averages from 3.4 to 3.5 inches. An- 
other, called by Wood the lower or inclined conjugate diameter, is 
that between the centre of the lower margin of the symphysis pubis 
and the promontory of the sacrum, and averages half an inch more 
than the antero-posterior diameter of the brim. These measurements 
are chiefly of importance in relation to certain pelvic deformities. 

External Measurements. — The external measurements of the pelvis 
are of no real consequence in normal parturition, but they may help 
us, in certain cases, to estimate the existence and amount of deformi- 
ties. Those which are generally given are: Between the anterior- 
superior iliac spines, 10 inches; between the central points of the 
crests of the ilia, 10J inches; between the spinous process of the last 
lumbar vertebra and the upper part of the symphysis pubis (external 
conjugate), 7 inches. 

Planes of the Pelvis. — By the planes of the pelvis are meant imagi- 
nary levels at any portion of its circumference. If we were to cut 



36 



ORGANS CONCERNED IN PARTURITION 



out a piece of cardboard so as to fit the pelvic cavity, and place it 
either at the brim or elsewhere, it would represent the pelvic plane 
at that particular part, and it is obvious that we may conceive as 
many planes as we desire. Observation of the angle which the 
pelvic planes form with the horizon shows the great obliquity at 
which the pelvis is placed in regard to the spinal column. Thus 
the angle abi (Fig. 9) represents the inclination to the horizon of 




Planes of the Pelvis with Horizon. 
A. B. Horizon. CD. Vertical line. 

abi. Angle of inclination of pelvis to horizon, eqnal to 6')°. 
b i c. Angle of inclination of pelvis to spinal column, equal to 150°. 
c i J. Angle of inclination of sacrum to spinal column, equal to 130°. 
e f. Axis of pelvic inlet. i- m. Mid plane in the middle line. 

n. Lowest point of mid plane of ischium. 

the plane of the pelvic brim I b, and is estimated to be about 60°, 
while the angle which the same plane forms with the vertebral 
column is about 150°. The plane of the outlet forms, with the 
coccyx in its usual positiou, an angle with the horizon of about 11°, 
but which varies greatly with the movements of the tip of coccyx, 
and the degree to which it is pushed back during parturition. These 
figures must only be taken as giving an approximative idea of the 
inclination of the pelvis to the spinal column, and it must be remem- 
bered that the degree of inclination varies considerably in the same 
female at different times, in accordance with the position of the body. 
During pregnancy especially, the obliquity of the brim is lessened by 
the patient throwing herself backwards in order to support more 
easily the weight of the gravid uterus. The height of the promon- 
tory of the sacrum above the upper margin of the symphysis pubis 



ANATOMY OF THE PELVIS 



37 



is on an average about 3} inches, and a line passing horizontally 
backwards from the latter point would impinge on the junction of 
the second and the third coccygeal bones. 

Axes of the Parturient Canal. — By the axis of the pelvis is meant 
an imaginary line which indicates the direction which the foetus 
takes during its expulsion. The axis of the brim (Fig. 10) is a line 

Fig. 10. 




A. Axis of superior plane. ] 

D. Axis of canal 



Axes of the Pelvis. 
5. Axis of mid plane. 



C Axis of inferioi 
Horizon. 



plane. 



drawn perpendicular to its plane, which would extend from the um- 
bilicus to about the apex of the coccyx ; the axis of the outlet of the 
bony pelvis intersects this, and extends from the centre of the pro- 
montory of the sacrum to midway between the tuberosities of the 
ischia. The axis of the entire pelvic canal is represented by the sum 
of the axes of an indefinite number of planes at different levels of 
the pelvic cavity, which forms an irregular parabolic line, as repre- 
sented in the accompanying diagram (Fig. 10, A d). 

It must be borne in mind, however, that it is not the axis of the 
bony pelvis alone that is of importance in obstetrics. We must 
always, in considering this subject, remember that the general axis 
of the parturient canal (Fig. 11) also includes that of the uterine 
cavity above, and of the soft parts below. These are variable in 
direction according to circumstances ; and it is only the axis of that 
portion of the parturient canal extending between the plane of the 
pelvic brim and a plane between the lower edge of the pubic sym- 
physis and the base of the coccyx that is fixed. The axis of the 
lower part of the canal will vary according to the amount of disten- 
sion of the perineum during labor ; but when this is stretched to 
its utmost, just before the expulsion of the head, the axis of the plane 






38 



ORGANS CONCERNED IN PARTURITION. 



between the edge of the distended perineum and the lower border of 
the symphysis, looks nearly directly forwards. The axis of the ute- 
rine cavity generally corresponds with that of the pelvic brim, but 



Fig. 11. 




[Representing General Axis of Parturient Canal, including the Uterine Cavity and Soft Parts. 

it may be much altered by abnormal positions of the uterus, such as 
anteversion from laxit}^ of the abdominal walls. The foetus, under 
such circumstances, will not enter the brim in its proper axis, and 
difficulties in the labor arise. A knowledge of the general direction 

of the parturient canal is of great 
Fig. 12. importance in practical midwifery 

in guiding us to the introduction of 
the hand or instruments in obstetric 
operations, and in showing us how 
to obviate difficulties arisino- from 
such accidental deviations of the 
uterus as have been just alluded to. 
Cavity of the Pelvis. — The ar- 
rangements of the bones in the in- 
terior of the pelvic canal (Fig. 12) 
are important in relation to the 
mechanism of delivery. A line 
passing between the spine of the 
ischium and the ilio-pectineal emi- 
nence divides the inner surface of 
side view of Pelvis. ischial bone into two smooth plane 




ANATOMY OF THE PELVIS. 89 

surfaces, which have received the name of the planes of the ischium. 
Two other planes are formed by the inner surfaces of the pubic 
bones in front and by the upper portion of the sacrum behind, 
both having a direction downwards and backwards. In studying the 
mechanism of delivery, it will be seen that many obstetricians at- 
tribute to these planes, in conjunction with the spine of the ischium, 
a very important influence in effecting rotation of the foetal head 
from the oblique to the anteroposterior diameter of the pelvis. 

Development of the Pelvis. — The peculiarities of the pelvis during 
infancy and childhood are of interest as leading to a knowledge of 
the manner in which the form observed during adult life is impressed 
upon it. The sacrum in the pelvis of the child (Fig. 13) is less cle- 

Fig. 13. 



Pelvis of a Child. 



veloped transversely, and is much less deeply curved than in the 
adult. The pubes is also much shorter from side to side, and the 
pubic arch is an acute angle. The result of this narrowness of both 
the pubes and sacrum is that the transverse diameter of the pelvic 
brim is shorter instead of longer than the antero-posterior. The sides 
of the pelvis have a tendency to parallelism, as well as the antero- 
posterior walls ; and this is stated by Wood to be a peculiar charac- 
teristic of the infantile pelvis. The iliac bones are not spread out as 
in adult life, so that the centres of the crests of the ilium are not 
more distant from each other than the anterior superior spines. The 
cavity of the true pelvis is small, the tuberosities of the ischia are 
proportionately nearer to each other than they afterwards become ; 
the pelvic viscera are consequently crowded up into the abdominal 
cavity, which is, for this reason, much more prominent in children 
than in adults. The bones are soft and semi-cartilaginous until alter 
the period of puberty, and yield readily to the mechanical infliien 
to which they are subjected; and the three divisions of the innomi- 
nate bone remain separate until about the twentieth year. 

As the child grows older the transverse development of the sacrum 
increases, and the pelvis begins to assume more and more of the adult 






40 ORGANS CONCERNED IN PARTURITION. 

shape. The mere growth of the bones, however, is not sufficient to 
account for the change in the shape of the pelvis, and it has been 
well shown by Duncan that this is chiefly produced by the pressure 
to which the bones are subjected during early life. The iliac bones 
are acted upon by two principal and opposing forces. One is the 
weight of the body above, which acts vertically upon the sacral ex- 
tremity of the iliac beam through the strong posterior sacro-iliac 
ligaments, and tends to throw the lower or acetabular ends of the 
sacro-cotyloid beams outwards. This outward displacement, how- 
ever, is resisted, partly by the junction between the two acetabular 
ends at the front of the pelvis, but chiefly by the opposing force, 
which is the upward pressure of the lower extremities through the 
femurs. The result of these counteracting forces is that the still 
soft bones bend near their junction with the sacrum ; and thus the 
greater transverse development of the pelvic brim characteristic of 
adult life is established. In treating of pelvic deformities it will be 
seen that the same forces applied to diseased and softened bones ex- 
plain the peculiarities of form that they assume. 

Pelvis in Different Races. — The researches that have been made on 
the differences of the pelvis in different races prove that these are 
not so great as might have been expected. Joulin pointed out that 
in all human pelves the transverse diameter was larger than the 
antero-posterior, while the reverse was the case in all the lower 
animals, even in the highest simise. This observation has been more 
recently confirmed by Yon Franque, 1 who has made careful measure- 
ments of the pelvis in various races. In the pelvis of the gorilla 
the oval form of the brim, resulting from the increased length of the 
conjugate diameter, was very marked. In certain races there is so 
far a tendency to animality of type, that the difference between the 
transverse and conjugate diameters is much less than in European 
women, but is not sufficiently marked to enable us to refer any given 
pelvis to a particular race. Yon Franque makes the general obser- 
vation that the size of the pelvis increases from South to North, but 
that the conjugate diameter increases in proportion to the transverse 
in southern races. 

Soft Parts in Connection with Pelvis. — In closing the description of 
the pelvis, the attention of the student must be directed to the mus- 
cular and other structures which cover it. It has already been 
pointed out that the measurements of the pelvic diameters are con- 
siderably lessened by the soft parts, which also influence parturition 
in other ways. Thus attached to the crests of the ilia are strong 
muscles which not only support the enlarged uterus, during pregnancy, 
but are powerful accessory muscles in labor : in the pelvic cavity are 
the obturator and pyriformis muscles lining it on either side ; the . 
pelvic cellular tissue and fasciae ; the rectum and bladder ; the vessels 
and nerves, pressure on which often gives rise to cramps and pains 
during pregnancy and labor ; while below the outlet of the pelvis is 
closed, and its axis directed forwards, by the numerous muscles form- 
ing the floor of the pelvis and perineum. 

1 Scanzoni's Beitrage, 1867. 



THE FEMALE GENERATIVE ORGANS. 41 



CHAPTEE II. 

THE FEMALE GENERATIVE ORGANS. 

Division according to Function. — The reproductive organs in the 
female are conveniently divided, according to their functions, into : 
1, The external or copulative organs, which are chiefly concerned in 
the act of insemination, and are only of secondary importance in 
parturition: they include all the organs situated externally which 
form the vulva; and the vagina, which is placed internally and forms 
the canal of communication between the uterus and the vulva. 2, 
The internal or formative organs : they include the ovaries, which 
are the most important of all, as being those in which the ovule is 
formed; the Fallopian tubes, through, which the ovule is carried to 
the uterus; and the uterus, in which, the impregnated ovule is lodged 
and developed. 

1. The external organs consist of: — 

Mons Veneris. — The rnons veneris, a cushion of adipose and fibrous 
tissue which forms a rounded projection at the upper part of the 
vulva. It is in relation above with the lower part of the hypogastric 
region, from which it is often separated by a furrow, and below it is 
continuous with the labia majora on either side. It lies over the 
symphysis and horizontal rami of the pubes. After puberty it is 
covered with hair. On its integument are found the openings ot 
numerous sweat and sebaceous glands. 

Labia Majora. — The labia majora form two symmetrical sides to 
the longitudinal aperture of the vulva. They have two surfaces, one 
external, of ordinal integument, covered with hair, and another 
internal, of smooth mucous membrane, in apposition with the corre- 
sponding portion of the opposite labium, and separated from the 
external surface by a free convex border. They are thicker in front, 
Avhere they run into the mons veneris, and thinner behind, where 
they are united, in front of the perineum, by a thin fold of integu- 
ment called the fourchette, which is almost invariably ruptured in 
the first labor. In the virgin the labia are closely in apposition, and 
conceal the rest of the generative organs. After child-bearing they 
become more or less separated from each other, and in the aged they 
waste, and the internal nymphae protrude through them. Both their 
cutaneous and mucous surfaces contain a large number of sebaceous 
glands, opening either directly on the surface or into the hair follicles. 
In structure the labia are composed of connective tissue, containing 
a varying amount of fat, and parallel with their external surface are 
placed tolerably close plexuses of elastic tissue, inters] >crscd with 
regularly arranged smooth muscular fibres. These fibres are described 
by Broca as forming a membranous sac, resembling the dartos of the 
4 



42 ORGANS CONCERNED IN PARTURITION. 

scrotum, to which the labia majora are analogous. Towards its upper 
and narrower end this sac is continuous with the external inguinal 
ring, and in it terminate some of the fibres of the round ligament. 
The analogy with the scrotum is further borne out by the occasional 
hernial protrusion of the ovary into the labium, corresponding to the 
normal descent of the testis in the male. 

Labia Minora. — The labia minora, or nymphae, are two folds of 
mucous membrane, commencing below, on either side, about the 
centre of the internal surface of the labium externum ; they converge 
as they proceed upwards, bifurcating as they approach each other. 
The lower branch of this bifurcation is attached to the clitoris, while 
the upper and larger uDites with its fellow of the opposite side, and 
forms a fold round the clitoris, known as its prepuce. The nymphae 
are usually entirely concealed by the labia majora, but after child- 
bearing and in old age they project somewhat beyond them; then 
they lose their delicate pink color and soft texture, and become brown, 
dry, and like skin in appearance. This is especially the case in some 
of the negro races, in whom they form long projecting folds called 
the apron. 

The surfaces of the nymphae are covered with a tesselated epithe- 
lium, and over them are distributed a large number of vascular 
papillae, somewhat enlarged at their extremities, and sebaceous 
glands, which are more numerous on their internal surfaces. The 
latter secrete an odorous, cheesy matter, which lubricates the surface 
of the vulva, and prevents its folds adhering to each other. The 
nymphae are composed of trabeculae of connective tissue, containing 
muscular fibres. 

Clitoris. — The clitoris is a small erectile tubercle situated about 
half an inch below the anterior commissure of the labia majora. It 
is the analogue of the penis in the male, and is similar to it in struc- 
ture, consisting of a corpus cavernosum, the two halves of which are 
separated by a fibrous septum. The crura are covered by the ischio- 
cavernous muscles, which serve the same purpose as in the male. It 
has also a suspensory ligament. The corpora cavernosa are composed 
of a vascular plexus with numerous traversing muscular fibres. The 
arteries are derived from the perineal artery, and give a branch, the 
cavernous, to each half of the organ; there is also a dorsal arter}- 
distributed to the prepuce. According to Gussenbauer these caver- 
nous arteries pour their blood directly into large veins, and a finer 
venous plexus near the surface receives arterial blood from small 
arterial branches. By these arrangements the erection of the organ 
which takes place during sexual excitement is favored. The nervous 
supply of the clitoris is large, being derived from the internal pudic 
nerve, which supplies branches to the corpora cavernosa, and termi- 
nates in the glands and prepuce, where Paccinian corpuscles and ter- 
minal bulbs are to be found. On this account the clitoris has been 
supposed by some to be the chief seat of voluptuous sensation in the 
female. 

Vestibule. — The vestibule is a triangular space, bounded at its apex 
by the clitoris, and on either side by the folds of the nymphae. It is 



THE FEMALE GENERATIVE ORGANS. 43 

smooth, and, unlike the rest of -the vulva, is destitute of sebaceous 
glands, although there are several groups of muciparous glands open- 
ing on its surface. At the centre of the base of the triangle which 
is formed by the upper edge of the opening of the vagina, is a promi- 
nence, distant about an inch from the clitoris, on which is the orifice 
of the urethra. This prominence can be readily made out by the 
finger, and the depression upon it — leading to the urethra — is of im- 
portance as our guide in passing the female catheter. This little 
operation ought to be performed without exposing the patient, and 
it is done in several ways. The easiest is to place the tip of the 
index finger of the left hand (the patient lying on her back) on the 
apex of the vestibule, and slip it gently down until we feel the bulb 
of the urethra, and the dimple of its orifice, which is generally readily 
found. If there is any difficulty in finding the orifice, it is well to 
remember that it is placed immediately below the sharp edge of the 
lower border of the symphysis pubis, which will guide us to it. The 
catheter (and a male elastic catheter is always the best, especiallv 
during labor, when the urethra is apt to be stretched) is then passed 
under the thigh of the patient, and directed to the orifice of the 
urethra by the finger of the left hand, which is placed upon it. We 
must be careful that the instrument is really passed into the urethra, 
and not into the vagina. It is advisable to have a few feet of elastic 
tubing attached to the end of the catheter, so that the urine can be 
passed into a vessel under the bed without uncovering the patient. 
If the patient be on her side, in the usual obstetric position, the ope- 
ration can be more readily performed by placing the tip of the finger 
in the vagina and feeling its upper edge. The orifice of the urethra 
lies immediately above this, and if the catheter be slipped along the 
palmar surface of the finger, it can generally be inserted without 
much trouble. If, however, as is often the case during labor, the 
parts are much swollen, it may be difficult to find the aperture, and 
it is then always better to look for the opening than to hurt the 
patient by long-continued efforts to feel it. [In this country, the in- 
strument is almost always introduced when possible, with the woman 
on her back. — Ed.] 

Urethra. — The urethra is a canal 1 J inches in length, and it is inti- 
mately connected with the anterior wall of the vagina, through which 
it may be felt. It is composed of muscular and erectile tissue, and 
is remarkable for its extreme dilatability, a property which is turned 
to practical account in some of the operations for stone in the female 
bladder. 

Orifice of the Vagina. — The orifice of the vagina is situated imme- 
diately below the bulb of the urethra. In virgins it is a circular 
opening, but in women who have borne children or practised sexual 
intercourse, it is, in the undistended state, a vertical fissure. In 
virgins it is generally more or less blocked up by a fold of mucous 
membrane, containing some cellular tissue and muscular fibres, with 
vessels and nerves, which is known as the hymen. This is most often 
crescentic in shape, with the concavity of the crescent looking up- 






44 ORGANS CONCERNED IN PARTURITION. 

wards ; sometimes, "however, it is circular with a central opening, or 
cribriform ; or it may even be entirely imperforate, and this gives 
rise to the retention of the menstrual secretion. These varieties of 
form depend on the peculiar mode of development of the fold of 
vaginal mucous membrane which blocks up the orifice of the vagina 
in the foetus, and from which the hymen is formed. The density of 
the membrane also varies in different individuals. Most usually it 
is very slight, so as to be ruptured in the first sexual approaches, or 
even by some accidental circumstance, such as stretching the limbs, 
so that its absence cannot be taken as evidence of want of chastity. 
A knowledge of this fact is of considerable importance from a medi- 
co-legal point of view. Sometimes it is so tough as to prevent inter- 
course altogether, and may require division by the knife or scissors 
before this can be effected ; and at others it rather unfolds than rup- 
tures, so that it may exist even after impregnation has been effected, 
and it has been met with intact in women who have habitually led 
unchaste lives. [It may also form an obstacle to delivery, and re- 
quire to be incised before the foetus can be extruded. — Ed.] 

Carunculse Myrtiformes. — The carunculse myrtiformes are small 
fleshy tubercles, varying from two to five in number, situated round 
the orifice of the vagina, and which are supposed to be formed by 
the remains of the ruptured hymen. 

Vulvo-vaginal Glands. — Near the posterior part of the vaginal 
orifice, and below the superficial perineal fascia, are situated two 
conglomerate glands which are the analogues of Cowper's glands in 
the male. Each of these is about the size and shape of an almond, 
and is contained in a cellular fibrous envelope. Internally they are 
of a yellowish- white color, and are composed of a number of lobules 
separated from each other by prolongations of the external envelope. 
These give origin to separate ducts which unite into a common canal, 
about half an inch in length, which opens in front of the attached 
edge of the hymen in virgins, and in married women at the base of 
one of the carunculse myrtiformes. According to Huguier, the size of 
the glands varies much in different women, and they appear to have 
some connection with the ovary, as he has always found the largest 
gland to be on the same side as the largest ovary. They secrete a 
glairy, tenacious fluid, which is ejected in jets during the sexual 
orgasm, probably through the spasmodic action of the perineal mus- 
cles. At other times their secretion serves the purpose of lubri- 
cating the vulva, and thus preserves the sensibility of its mucous 
membrane. 

Fossa Navicularis. — Immediately behind the hymen in the un- 
married, and between it and the perineum, is a small depression 
called the fossa navicularis, which disappears after childbearing. 

Perineum. — The perineum separates the orifice of the vagina from 
that of the rectum. It is about 1J inches in breadth, and is of great 
obstetric interest, not only as supporting the internal organs from 
below, but because of its action in labor. It is largely stretched and 
distended by the presenting part of the child; and if unusually tough 



THE FEMALE GENERATIVE ORGANS 



45 



and unyielding may retard delivery, or it may be torn to a greater 
or less extent, thus giving rise to various subsequent troubles. 

Vascular Supply of the Vulva. — The structures described above 
together form the vulva, and they are remarkable for their abundant 
vascular and nervous supply. The former constitutes an erectile 
tissue similar to that which has already been described in the cli- 
toris, and which is especially marked about the bulb of the vestibule 
(Fig. 14). From this point, and extending on either side of the 

Fig. 14. 




Vascular Supply of Vulva. (After Kobelt.) 

n. Bulb of vestibule, b. Muscular tissue of vagiua. c,d,e,f. The clitoris and its muscles, g, h, 
i, k, I, m, n. Veins of the nymphse and clitoris communicating with the epigastric and obturator veins. 



vagina, there is a well-marked plexus of convoluted veins, which, in 
their distended state, are likened by Dr. Arthur Farre to a filled 
leech. The erection of the erectile tissue, as well as that of the 
clitoris, is brought about under excitement, as in the male, by the 
compression of the efferent veins by the contraction of the ischio- 
cavernous muscles, and by that of a thin layer of muscular tissues 
surrounding the orifice of the vagina, and described as the constrictor 
vaginae. 

Vagina. — The vagina is the canal which forms the communication 
between the external and internal generative organs, through which 
the semen passes to reach the uterus, the menses flow, and the foetus 
is expelled. Koughly speaking, it lies in the axis of the pelvis, but 
its opening is placed anterior to the axis of the pelvic outlet, so that 
its lower portion is curved forwards. It is narrow below, but dilated 
above, where the cervix uteri is inserted into it, so that it is more or 



46 



ORGANS CONCERNED IN PARTURITION 



less conoiclal in shape. Generally speaking, its anterior and posterior 
walls lie closely in contact, but they are capable of very wide dis- 
tension, as during the passage of the foetus. The anterior wall of 
the vagina is shorter than the posterior, the former measuring on an 
average 2 J inches, the latter 3 inches; but the length of the canal 
varies greatly in different subjects and under certain circumstances. 
In front the vagina is closely connected with the base of the bladder, 
so that when the vagina is prolapsed, as often occurs, it drags the 
bladder with it (Fig. 15); behind, it is in relation with the rectum, 



Fig. 15. 




Longitudinal Section of Body, showing Kelatious of Generative Organs. 

but less intimately; laterally with the broad ligaments and pelvic 
fascia; and superiorly with the lower portion of the uterus and folds 
of peritoneum both before and behind. The vagina is composed of 
mucous, muscular, and cellular coats. The mucous lining is thrown 
into numerous folds. These start from longitudinal ridges which 
exist on both the anterior and posterior walls, but most distinctly on 
the anterior. They are very numerous in the young and unmarried, 
and greatly increase the sensitive surface of the vagina. After child- 
bearing, and in the aged, they become atrophied, but they never 
completely disappear, and towards the orifice of the vagina, where 
they exist in greatest abundance, they are always to be met with. 
The whole of the mucous membrane is lined with tesselated epithe- 
lium, and it is covered with a large number of papillae either conical 
or divided, which are highly vascular and project into the epithelial 



THE FEMALE GENERATIVE ORGANS. 47 

layer. Unlike the vulvar mucous membrane, that of the vagina 
seems to be destitute of glands. Beneath the epithelial layer is a 
submucous tissue containing a large number of elastic and some 
muscular fibres, derived from the muscular walls of the vagina. These 
are strong and well- developed, especially towards the ostium vaginae. 
They consist of two layers — an internal longitudinal, and an external 
circular — with oblique decussating fibres connecting the two. Below 
they are attached to the ischio-pubic rami, and above they are con- 
tinuous with the muscular coat of the uterus. The muscular tissue 
of the vagina increases in thickness during pregnancy, but to a much 
less degree than that of the uterus. Its vascular arrangements, like 
those of the vulva, are such as to constitute an erectile tissue. The 
arteries form an intricate network around the tube, and eventually 
end in a submucous capillary plexus, from which twigs pass to supply 
the papillae; these again give origin to venous radicles which unite 
into meshes freely interlacing with each other, and forming a well- 
marked venous plexus. 

Internal Organs of Generation. — 2. The internal organs of gene- 
ration consist of the uterus, the Fallopian tubes, and the ovaries ; 
and in connection with them we have to study the various ligaments 
and folds of peritoneum which serve to maintain the organs in posi- 
tion, along with certain accessory structures. Physiologically, the 
most important of all the generative organs are the ovaries, in which 
the ovules are formed, and which dominate the entire reproductive 
life of the female. The Fallopian tubes which convey the ovule to 
the uterus, and the uterus itself — whose main function is to receive, 
nourish, and eventually expel the impregnated product of the ovary — 
may be said to be, in fact, accessory to these viscera. Practically, 
however, as obstetricians, we are chiefly concerned with the uterus, 
and may conveniently commence with its description. 

Uterus. — The uterus is correctly described as a pyriform organ, 
flattened from before backwards, consisting of the body, with its 
rounded fundus, and the cervix which projects into the upper part 
of the vaginal canal. In the adult female it is deeply situated in 
the pelvis, being placed between the bladder in front and the rectum 
behind, its fundus being below the plane of the pelvic brim (Fig. 16). 
It only assumes this position, however, towards the period of puberty ; 
and in the foetus it is placed much higher, and lies, indeed, entirely 
within the cavity of the abdomen. It is maintained in this position 
partly by being slung by its ligaments, which Ave shall subsequently 
study, and partly by being supported from below by the pelvic cel- 
lular tissue and the fleshy column of the vagina. The result is that 
the uterus, in the healthy female, is a perfectly movable body, alter- 
ing its position to suit the condition of the surrounding viscera, 
especially the bladder and rectum, which are subjected to variations 
of size according to their fulness or emptiness. When from any 
cause — as, for example, some peri-uterine inflammation producing 
adhesions to the surrounding textures — the mobility of the organ is 
interfered with, much distress ensues, and if pregnancy supervenes 
more or less serious consequences may result. Generally speaking, 






48 



ORGANS CONCERNED IN PARTURITION. 



the uterus may be said to lie in a line roughly corresponding with 
the axis of the pelvic brim, its fundus being pointed forwards and 
its cervix lying in such a direction that a line drawn from it would 
impinge on the junction between the sacrum and coccyx. According 



Fig. 16. 




Transverse Section of the Body, showing Eelations of the Fundus Uteri. 

m. Puhes. a, a (in front), Remainder of hypogastric arteries, <7, a (behind), Spermatic vessels 
and nerves. B. Bladder. L, L. Round ligaments. IT. Fundus uteri, t, t. Fallopian tubes, o, o. 
Ovaries, r. Rectum, g. Right ureter, resting on the psoas muscle, c. Utero-sacral ligaments, v 
Last lumbar vertebra. 

to some authorities, the uterus in early life is more curved in the 
anterior direction, and is, in fact, normally in a state of ante-flexion. 
Sappey holds that this is not necessarily the case, but that the amount 
of anterior curvature depends on the emptiness or fulness of the 
bladder, on which the uterus, as it were, moulds itself in the unim- 
pregnated state. It is believed also that the body of the uterus is 
very generally twisted somewhat obliquely, so that its anterior sur- 
face looks a little towards the right side, this probably depending on 
the presence and frequent distension of the rectum in the left side of 
the pelvis. The anterior surface of the uterus is convex, and is 
covered in three-fourths of its extent by the peritoneum, which is 
intimately adherent to it. Below the reflection of that membrane it 
is loosely connected by cellular tissue to the bladder, so that any 
downward displacement of the uterus drags the bladder along with it. 
The posterior surface is also convex, but more distinctly so than the 
anterior, as may be observed in looking at a transverse section of 
the organ (Fig. 17). It is also covered by peritoneum, the reflection 
of which on the rectum forms the cavity known as Douglas's pouch. 
The fundus is the upper extremity of the uterus, lying above the 



THE FEMALE GENERATIVE ORGANS. 



49 



points of entry of the Fallopian tubes. It is only slightly rounded 
in the virgin, but b°comes more decidedly and permanently rounded 
in the woman who has borne children. 



Fig. 1 




Transverse Section of Uterus. 



Dimensions. — Until the period of puberty the uterus remains small 
and undeveloped (Fig. 18) ; after that time it reaches the adult size, 
at which it remains until menstruation ceases, when it again atrophies. 
If the woman has borne children, it always remains larger than in 
the nullipara. In the virgin adult the uterus measures 2J inches 
from the orifice to the fundus, rather more than half being taken up 

Fig. 18. 




Uterus and AppeDdages in an Infant. (After Farre.) 

by the cervix. Its greatest breadth is opposite the insertion of the 
Fallopian tubes; its greatest thickness, about 11 or 12 lines, oppo- 
site the centre of its body. Its average weight is about 9 or 1" 
drachms. Independently of pregnancy, the uterus is subject to great 
alterations of size towards the menstrual period, when on account of 
the congestion then present, it enlarges, sometimes, it is said, con- 
siderably. This fact should be borne in mind, as this periodical 
swelling might be taken for an early pregnancy. 



50 ORGANS CONCERNED IN PARTURITION. 

Regional Divisions. — For the purpose of description the uterus is 
conveniently divided into the fundus, with its rounded upper ex- 
tremity, situated between the insertions at the Fallopian tubes; the 
body, which is bounded above by the insertion of the Fallopian tubes, 
and below by the upper extremity of the cervix, and which is the 
part chiefly concerned in the reception and growth of the ovum ; and 
the cervix, which projects into the vagina, and dilates during labor 
to give passage to the child. The cervix is conical in shape, measur- 
ing 11 to 12 lines transversely at the base, and 6 or 7 in the antero- 
posterior direction ; while at the apex it measures 7 to 8 transversely, 
and 5 antero-posteriorly. It projects about 4 lines into the canal of 
the vagina, the remainder of the cervix being placed above the 
reflection of the vaginal mucous membrane. It varies much in form 
in the virgin and nulliparous married woman, and in the woman 
who has borne children; and the differences are of importance in 
the diagnosis of pregnancy and uterine disease. In the virgin it is 
regularly pyramidal in shape. At its lower extremity is the opening 
of the external os uteri, forming a small transverse fissure, sometimes 
difficult to feel, and generally described as giving a sensation to the 
examining finger like the extremity of the cartilage at the tip of the 
nose. It is bounded by two lips, the anterior of which is apparently 
larger on account of the position of the uterus. The surface of the 
cervix, and the borders of the os, are very smooth and regular. 

Changes after Childbirth. — In women who have borne children 
these parts become considerably altered. The cervix is no longer 
conical, but is irregular in form and shortened. The lips of the os 
uteri become fissured and lobulated, on account of partial lacerations 
which have occurred during labor. The os is larger and more irregu- 
lar in outline, and is sometimes sufficiently patulous to admit the tip 
of the finger. In old age the cervix atrophies, and after the change 
of life it not uncommonly entirely disappears, so that the orifice of 
the os uteri is on a level with the roof of the vagina. 

, Internal Surface of the Uterus. — The internal surface of the uterus 
comprises the cavities of the body and cervix — the former being 
rather less than the latter in length in virgins, but about equal in 
women who have borne children — separated from each other by 
a constriction forming the upper boundary of the cervical canal. 
The cavity of the body is triangular in shape, the base of the triangle 
being formed by a line joining the openings of the Fallopian tubes, 
its apex by the upper orifice of the cervix, or internal os, as it is 
sometimes called. In the virgin its boundaries are somewhat convex, 
projecting inwards. After childbearing they become straight or 
slightly concave. The opposing surfaces of the cavity are always in 
contact in the healthy state, or are only separated from each other 
by a small quantity of mucus. 

Cavity of the Cervix. — The cavity of the cervix is spindle-shaped 
or fusiform, narrower above and below, at the internal and external 
os uteri, and somewhat dilated between these two points. It is flat- 
tened from before backwards, and its opposing surfaces also lie in 
contact, but not so closely as those of the body. On the mucous 



THE FEMALE GENERATIVE ORGANS 



51 



lining of the anterior and posterior surfaces is a prominent perpen- 
dicular ridge, with a lesser one at each side, from which transverse 
ridges proceed at more or less acute angles. These have received 
the name of the arbor vitas. According to Gruyon the perpendicular 
ridges are not exactly opposite, so that they fit into each other, and 
serve more completely to fill up the cavity of the cervix, especially 
towards the internal os (Fig. 19). The arbor vitas is most distinct 
in the virgin, and atrophies considerably after childbearing. 

Fig. 19. 




Portion of Interior of Cervix. (Enlarged nine diameters.) (After Tyler Smith and Hassall.) 

The superior extremity of the cervical canal forms a narrow 
isthmus separating it from the cavity of the body, and measuring 
about |ths of an inch in diameter. Like the external os, it contracts 
after the cessation of menstruation, and in old age sometimes be- 
comes entirely obliterated. 

Structure of the Uterus. — The uterus is composed of three principal 
structures — the peritoneal, muscular, and mucous coats. The peri- 
toneum forms an investment to the greater part of the organ, ex- 
tending downwards in. front to the level of the os internum, and 
behind to the top of the vagina, from which points it is reflected 
upwards on the bladder and rectum respectively. At the sides the 
peritoneal investment is not so extensive, for a little below the level 
of the Fallopian tubes the peritoneal folds separate from each other, 
forming the broad ligaments (to be afterwards described) ; here it is 
that the vessels and nerves supplying the uterus gain access to it. 
At the upper part of the organ the peritoneum is so closely adherenl 



52 



ORGANS CONCERNED IN PARTURITION. 



Fig. 20. 



to the muscular tissue that it cannot be separated from it ; below the 
connection is more loose. The mass of the uterine tissue, both in 

the body and cervix, consists of 
unstriped muscular fibres, firmly 
united together by nucleated con- 
nective tissue and elastic fibres. 
The muscular fibre cells are large 
and fusiform, with very attenuated 
extremities, generally containing 
in their centre a distinct nucleus. 
These cells, as well as their nuclei, 
become greatly enlarged during 
pregnancy (Fig. 21); according to 
Strieker, this is only the case with 
the muscular fibres which play an 
important part in the expulsion of the foetus, those of the outermost 
and innermost layers not sharing in the increase of size. 1 In addi- 
tion to these developed fibres there are, especially near the mucous 
coat, a number of round elementary corpuscles, which are believed 




Muscular Fibres of unimpregnated Uterus 

(After Farre.) 
a. Fibres united by connective tissue. 
Separate fibres and elementary corpuscles. 



Fig. 21. 




Developed Mi 



Gravid Uterus. (After Wagner.) 



by Dr. Farre 2 to be the elementary form of the muscular fibres, and 
which he has traced in various intermediate states of development. 
Dr. John "Williams 3 believes that a great part of the muscular tissue 
of the uterus, rather more indeed than three-fourths of its thickness, 
is an integral part of the mucous membrane, analogous to the mus- 
cularis mucosas of the mucous membrane of the alimentary canal. 
This he describes as being separated from the rest of the muscular 
tissue by a layer of rather loose connective tissue, containing nume- 
rous vessels. In early foetal life, and in the uteri of some of the 
lower animals, this appearance is very distinct ; in the adult female 
uterus, however, it cannot be readily made out. 

Arrangement of the Muscular Fibres. — On examining the uterine 
tissue in an unimpregnated condition no definite arrangement of its 
muscular fibres can be made out, and the whole seem blended in in- 
extricable confusion. By observation of their relations when hyper- 



1 Comparative Histology, vol. iii., Syrt. Soc. Trans., p 47 7. 

2 The Uterus and its Appendages, p. G.'>2. 

3 "On the Structure of the Mucous Membrane of the Uterus, 
1875. 



Obstet. Journ., 



THE FEMALE GENERATIVE ORGANS. 53 

trophied during pregnancy, Helie 1 has shown that they may, speaking 
roughly, be divided into three layers : an external ; a middle, chiefly 
longitudinal ; and an internal, chiefly circular. Into the details of 
their distribution, as described by him, it is needless to enter at length. 
Briefly, however, he describes the external layer as arising posteriorly 
at the junction of the body and cervix, and spreading upwards and 
over the fundus. From this are derived the muscular fibres found in 
the broad and round ligaments, and more particularly described by 
Rouget. The middle layer is made up of strong fasciculi, which run 
upwards, but decussate and unite with each other in a remarkable 
manner, so that those which are at first superficial become most 
deeply seated, and vice versa. The muscular fasciculi which form 
this coat curve in a circular manner around the large veins, so as to 
form a species of muscular canal through which they run. This 
arrangement is of peculiar importance, as it affords a satisfactory ex- 
planation of the mechanism by which hemorrhage after delivery is 
prevented. The internal layer is mainly composed of circular rings 
of muscular fibres, beginning round the openings of the Fallopian 
tubes, and forming wider and wider circles which eventually touch 
and interlace with each other. They surround the internal os, to 
which they form a kind of sphincter. In addition to these circular 
fibres on the internal uterine surface, both anteriorly and posteriorly, 
there is a well-marked triangular layer of longitudinal fibres, the 
base being above and the apex below, which sends muscular fasciculi 
into the mucous membrane. 

Its Mucous Membrane. — The anatomy of the lining membrane of 
the uterus has been the subject of considerable discussion. Its exist- 
ence has been denied by many authorities, most recently by Snow 
Beck, 2 who maintains that it is in no sense a mucous membrane, but 
only a softened portion of true uterine tissue. It is, however, pretty 
generally admitted by the best authorities that it is essentially a mu- 
cous membrane, differing from others only in being more closely 
adherent to the subjacent structures, in consequence of not possess- 
ing any definite connective tissue framework. 

It is a pale pink membrane of considerable thickness, most marked 
at the centre of the body, where it forms from Jth to Jth of the 
thickness of the whole uterine walls. At the internal os uteri it ter- 
minates by a distinct border, which separates it from the mucous 
membrane lining the cervical cavity. 

The Utricular Glands. — On the surface of the mucous membrane 
may be observed a multitude of little openings, about ^th of a line 
in width (Fig. 22). These are the orifices of the utricular glands, 
which are found in immense numbers all over the cavity of the 
uterus, and very closely agglomerated together. They are Little culs- 
de-sac, narrower at their mouths than in their length, the blind ex- 
tremities of which are found in the subjacent tissues. Williams 
describes them as running obliquely towards the surface at the Lower 

1 Recherches sur la disposition des Fibres musculaires de 1' Uterus. Paris, L869. 

2 Obst. Trans., vol. xiii. p. 294. 



54 



ORGANS CONCERNED IN PARTURITION. 



third of the cavity, perpendicularly at its middle, while towards the 
fundus they are at first perpendicular, and then oblique in their 




Fig. 23. 



Lining Membrane of Uterus, showing network of Capillaries and Orifices of Uterine Glands. 

(After Farre.) 
Prom the body. From orifice of Fallopian tube. 

course (Fig. 23). By others they are described as being often twisted 
and corkscrew-like. One or more may unite to form a common 
orifice, several of which may open together in little pits or depres- 
sions on the surface of the mucous membrane. These glands are 

composed of structureless membrane lined 
with epithelium, the precise character of 
which is doubtful. By some it is described 
as columnar, by others tesselated, and by 
some again as ciliated. The most gener- 
ally received opinion is that it is columnar, 
but not ciliated ; therein differing from 
the epithelium covering the surface of the 
membrane, which is undoubtedly ciliated, 
the movements of the cilia being from 
within outwards. Williams, however, has 
observed cilia in active movement on the 
columnar epithelium lining the glands, and 
also states that at the deep-seated extremi- 
ties of the glands, which penetrate between 
the muscular fibres for some distance, the 
columnar epithelium is replaced by rounded 
cells. The capillaries of the mucous mem- 
brane run down between the tubes, form- 
ing a lace -work on their surfaces, and 
round their orifices. No true papillae exist 
in 'the membrane lining the uterine cavity. 
The mucous membrane of the uterus is 
peculiar in being always in a state of 
change and alteration, being thrown oft' at 
each menstrual period in the form of debris, 
in consequence of fatty degeneration of its 
structures, and, reformed afresh by pro- 
liferation of the cells of the muscular and 
connective tissues, probably from below 
upwards, the new membrane commencing 
Hence its appearance and structure vary consid- 




The course of the Glands in the 
fully developed Mucous Mem- 
brane of the Uterus, viz., just be- 
fore the onset of a menstrual 
period. (After Williams.) 



at the internal os. 



THE FEMALE GENERATIVE ORGANS. 55 

erably according to the time at which it is examined. This subject, 
however, will be more particularly studied in connection with men- 
struation. 

Mucous Membrane of the Cervix. — The mucous membrane of the 
cervix is much thicker and more transparent than that of the body 
of the uterus, from which it also differs in certain structural peculiari- 
ties. The general arrangements of its folds and surface have already 
been described. The lower half of the membrane lining the cavity of 
the cervix, and the whole of that covering its external or vaginal por- 
tion, are closely set with a large number of minute filiform, or clavate 
papillae (Fig. 24). Their structure is similar to that of the mucous 

Fig. 24. 




Villi of Os Uteri stripped of Epithelium. (After Tyler Smith aud Hassall.) 

membrane itself, of which they seem to be merely elevations. They 
each contain a vascular loop (Fig. 25), and they are believed by 
Kilian and Farre to be mainly concerned in giving sensibility to this 
part of the generative tract. All over the interior of the cervix, 
both on the ridges of the mucous membrane and between their folds, 
are a very large number of mucous follicles, consisting of a structure- 
less membrane lined with cylindrical epithelium, and intimately 
united with the connective tissue. They cease at the external orifice 
of the cervix, and they secrete the thick, tenacious, and alkaline 
mucus which is generally found filling the cervical cavity. The 
transparent follicles, known as the "ovula Nabothii" which arc some- 
times found in considerable numbers in the cavity of the cervix, con- 
sist of mucous follicles the mouths of which have become obstructed, 
and their canals distended by mucous secretion. The lower third 



56 ORGANS CONCERNED IN PARTURITION. 

of the cervical canal, as well as the exterior of the cervix, are covered 
with pavement epithelium ; while on its upper portion is found a 
columnar and ciliated epithelium similar to that lining the uterine 
cavity. 

Fig. 25. 




Villi of uterus, covered with. Pavement Epithelium, and containing Looped Vessels. (After Tyler 

Smith and Hassall.) 

Vessels of the Uterus. — The arteries of the uterus are derived from 
the internal iliac, and from the ovarian. They enter the uterus be- 
tween the folds of the broad ligaments, and, penetrating its muscular 
coat, anastomose freely with each other and with the corresponding 
vessels of the opposite side. Their walls are thick and well-devel- 
oped, and they are remarkable for their very tortuous course, forming 
spiral curves, especially in the upper part of the uterus. They end 
in minute capillaries which form the fine meshes surrounding the 
glands, and in the cervix, give off the loops entering the papillae. 
Beneath the uterine mucous membrane these capillaries form a plexus, 
terminating in veins without valves, which unite with each other to 
form the large veins traversing the substance of the uterus, known 
during pregnancy as the uterine sinuses, the walls of which are closely 
adherent to the uterine tissues. These veins, freely anastomosing 
with each other, pass outwards to the folds of the broad ligaments, 
where they unite to form, with the ovarian and vaginal veins, a large 
and well-developed venous network, known as the pampiniform 
plexus. 

Lymphatics of the Uterus. — The lymphatics of the uterus are large 
and well developed, and they have recently, and with much proba- 
bility, been supposed to play an important part in the production of 
certain puerperal diseases. A more minute knowledge than we at 



THE FEMALE GENERATIVE ORGANS. 57 

present possess of their course and distribution will probably throw 
much light on their influence in this respect. According to the re- 
searches of Leopold, 1 who has studied their minute anatomy care- 
fully, they originate in lymph spaces between the fine bundles of 
connective tissue forming the basis of the mucous lining of the uterus. 
Here they are in intimate contact with the utricular glands and the 
ultimate ramifications of the uterine bloodvessels. As they pass 
into the muscular tissue they become gradually narrowed into lymph 
vessels and spaces, which have a very complicated arrangement, and 
which eventually unite together in the external muscular layer, espe- 
cially on the sides of the uterus, to form large canals which probably 
have valves. Immediately under the peritoneal covering these 
lymph -vessels form a large and characteristic network, covering the 
anterior and posterior surfaces of the uterus, and present, in various 
parts of their course, large ampullae. They then spread over the 
Fallopian tubes. The lymphatics of the body of the uterus unite 
with the lumbar glands, those of the cervix with the pelvic glands. 

Nerves of the Uterus. — The distribution and arrangement of the 
nerves of the uterus have been the subject of much controversy. 
They are derived mainly from the ovarian and hypogastric plexuses, 
inosculating freely with each other between the folds of the broad liga- 
ment, from which they enter the muscular tissue of the uterus gene- 
rally, but not invariably, following the course of the arteries. They 
are chiefly derived from the sympathetic; but, as the hypogastric 
plexus is connected with the sacral nerves, it is probable that some 
fibres from the cerebro-spinal system are distributed to the cervix. 
It is now generally admitted that nervous filaments are distributed 
to the cervix, even as far as the external os although their existence 
in this situation has been denied \>y Jobert and other writers. The 
ultimate distribution of the nerves is not yet made out. Polle de- 
scribes a nerve filament as entering the papillae of the cervical mu- 
cous membrane along with the capillary loop, and Frankenhauser 
says the nerve fibres surround the muscles of the uterus in the form 
of plexuses and terminate in the nuclei of the muscle cells. 

Anomalies of the Uterus. — Various abnormal conditions of the 
uterus and vagina are occasionally met with, which it is necessary 
to mention, as they may have an important practical bearing on 
parturition. The most frequent of these is the existence of a double, 
or partially double, uterus (Fig. 26), similar to that found normally 
in many of the lower animals. This abnormality is explained by the 
development of the organ during foetal life. The uterus is formed 
out of structures existing only in early foetal life, known as the 
Wolfian bodies. These consist of a number of tubes, situated on 
either side of the vertebral column, and opening internally into an 
excretory duct. Along their external border a hollow canal is 
formed, termed the canal of Miiller, which like the excretory duds, 
proceeds to the common cloaca of the digestive and urinary organs 
which then exists. The canal of Mullcr unites with its fellow of the 

• Arch. f. Gynak. Bd. vi. Heft i. 



58 



ORGANS CONCERNED IN PARTURITION. 



opposite side to form the uterus and Fallopian tubes in the female, 
and subsequently the central partition at their point of junction dis- 
appears. If, however, the progress of development be in any way 

Then we have produced 



checked, the central partition may remain. 



Fig. 26. 




Bifid Uterus. (After Farre.) 

either a complete double uterus or the uterus bicornis, which is bifid 
at its upper extremity only ; or a double vagina, each leading to 
a separate uterus. 

Pregnancy in cases of Bifid Uterus. — If pregnancy occur in any of 
these anomalous uteri, and many such cases are recorded, serious 
troubles may follow. It may happen that one horn of a double 
uterus is not sufficiently large to admit of pregnancy going on to 
term, and rupture may occur. It is supposed that some cases, pre- 
sumed to be tubal gestation, were really thus explicable. Impreg- 
nation may also occur in the two cornua at different times, leading 
to superfcetation. It is, however, quite possible that impregnation 
may occur in one horn of a bifid uterus, and labor be completed with- 
out anything unusual being observed. A remarkable case of this 
sort has been recorded by Dr. Eoss of Brighton, 1 in which a patient 
miscarried of twins on July 16, 1870, and on October 31, fifteen weeks 
later, she was delivered of a healthy child. Careful examination 
showed the existence of a complete double uterus, each side of which 
had been impregnated. Curiously enough, this patient had formerly 
given birth to six living children at term, nothing remarkable having 
been observed in her labors. It can only rarely happen, that, under 
such circumstances, so favorable a result will follow, and more or 
less difficulty and danger may generally be expected. Occasionally 
the vagina only is double, the uterus being single. Dr. Matthews 
Duncan has recorded some cases of this kind, 2 in which the vaginal 
septum formed an obstacle to the birth of the child, and required 
division. [It may also be associated with an obstinate form of vagi- 
nismus. — Ed.] 



1 Lancet, August, 1871. 

2 Researches in Obstetrics, p. 443. 



THE FEMALE GENERATIVE ORGANS. 59 

Ligaments of the Uterus. — The various folds of peritoneum which 
invest the uterus serve to maintain it in position, and they are de- 
scribed as its ligaments. They are the broad, the vesieo-uterine, and 
sacro-uterine ligaments ; the round ligaments are not peritoneal folds 
like the others. 

Broad Ligaments. — The broad ligaments extend from either side 
of the uterus, where their laminae are separated from each other, 
transversely across to the pelvic wall, and thus divide the cavity of 
the pelvis into two parts; the anterior containing the bladder, the 
posterior the rectum. Their upper borders are divided into three 
subsidiary folds, the anterior of which contains the round ligament, 
the middle the Fallopian tube, and the posterior the ovary. This 
arrangement has received the name of the ala vespertilionis, from its 
fancied resemblance to a bat's wing. Between the folds of the broad 
ligaments are found the uterine vessels and nerves, and a certain 
amount of loose cellular tissue continuous with the pelvic fascia?. 
Here is situated that peculiar structure called the organ of Bosen- 
miiller, or the parovarium (Fig. 27), which is the remains of the 

Fig. 27. 





Adult Parovarium, Ovary, and Fallopian Tube. (After Kobelt.) 

Wolffian body, and corresponds to the epididymis in the male. This 
may best be seen in young subjects, by holding up the broad liga- 
ments and looking through them by transmitted light; but it exists 
at all ages. It consists of several tubes (eight or ten according to 
Farre, eighteen or twenty according to Bankes), 1 which arc tortuous 
in their course. They are arranged in a pyramidal form, the base 
of the pyramid being towards the Fallopian tube, its apex being lost 
on the surface of the ovary. They are formed of fibrous tissue, and 
lined with pavement epithelium. They have no excretory duct, or 
communication with either the uterus or ovary, and their {'unction. 
if they have any, is unknown. 

1 Bankes, On the Wolffian Bodies. 



60 



ORGANS CONCERNED IN PARTURITION. 



Muscular Fibres between its Folds. — A number of muscular fibres 
are also found in this situation, lying between the meshes of the 
connective tissue. They have been particularly studied by Kouget, 
who describes them as interlacing with each, other, and forming an 
open network, continuous with, the muscular tissue of the uterus 

Fig. 28. 




Posterior View of Muscular and Vascular Arrangements. (After Kouget.) 

Vessels. — 1, 2,3. Vaginal, cervical, aud uterine plexuses. 4. Arteries of body of uterus. 5. Arteries 
supplying ovary. Muscular fasciculi.— 6, 7. Fibres attached to vagina, symphysis pubis, and sacro- 
iliac joint 8. Muscular fasciculi from uterus and broad ligaments. 9,10,11,12. Fasciculi attached 
to ovary and Fallopian tubes. 



(Fig. 28). They are divisible into two layers, the anterior of which 
is continuous with the muscular fibres of the anterior surface of the 
uterus, and goes to form part of the round ligament; the posterior 
arises from the posterior wall of the uterus, and proceeds transversely 
outwards, to become attached to the sacro-iliac synchondrosis. A 
continuous muscular envelope is thus formed, which surrounds the 
whole of the uterus, Fallopian tubes, and ovaries. Its function is 
not yet thoroughly established. It is supposed to have the effect of 
retracting the stretched folds of peritoneum after delivery, and more 
especially of bringing the entire generative organs into harmonius 
action during menstruation and the sexual orgasm; in this way 
explaining, as we shall subsequently see, the mechanism by which 



THE FEMALE GENERATIVE ORGANS. 61 

the fimbriated extremity of the Fallopian tube grasps the ovary 
prior to the rupture of a Graafian follicle. 

Round Ligaments. — The round ligaments are essentially muscular 
in structure. They extend from the upper border of the uterus, 
with the fibres of which their muscular fibres are continuous, trans- 
versely and then obliquely downwards, until they reach the inguinal 
rings, where they blend with the cellular tissue. In the first part of 
their course the muscular fibres are solely of the unstriped variety, 
but soon they receive striped fibres from the transversalis muscles, 
and the columns of the inguinal ring, which surround and cover the 
unstriped muscular tissue. In addition to these structures they con- 
tain elastic and connective tissue, and arterial, venous, and nervous 
branches ; the former form the iliac or cremasteric arteries, the latter 
the genito-crural nerve. According to Mr. Kainey the principal 
function of these ligaments is to draw the uterus towards the sym- 
physis pubis during sexual intercourse, and thus to favor the ascent 
of the semen. 

Vesicouterine Ligaments. — The vesico-uterine ligaments are two 
folds of peritoneum passing in front from the lower part of the body 
of the uterus to the fundus of the bladder. 

Utero-sacral Ligaments. — The utero-sacral ligaments consist of 
folds of peritoneum of a crescentic form, with their concavities look- 
ing inwards : they start from the lower part of the posterior surface 
of the uterus, and curve backwards to be attached to the third and 
fourth sacral vertebra. Within their folds exist bundles of muscu- 
lar fibres, continuous with those of the uterus, as well as connective 
tissue, vessels, and nerves. The experiments of Savage, as well as 
of other anatomists, show that these ligaments have an important 
influence in preventing downward displacement of the womb. 

Alterations during Pregnancy. — During pregnancy all these liga- 
ments become greatly stretched and unfolded, rising out of the pelvic 
cavity and accommodating themselves to the increased size of the 
gravid uterus ; and they again contract to their natural size, possibly 
through the agency of the muscular fibres contained within them, 
after delivery has taken place. 

Fallopian Tithes. — 'The Fallopian tubes, the homologues of the vasa 
deferentia in the male, are structures of great physiological interest. 
They serve the double purpose of conveying the semen to the ovary, 
and of carrying the ovule to the uterus. From the latter function 
they may be looked on as the excretory ducts of the ovaries; but, 
unlike other excretory ducts, they are movable, so that they may 
apply themselves to the part of the ovaries from which the ovule is 
to come ; and so great is their mobility, that there is reason to believe 
that a Fallopian tube may even grasp the ovary of the opposite side. 
[This has been established by a case where impregnation look place 
in an ovary, the Fallopian tube corresponding to which was imper- 
vious and immovable. — Ed.] Each tube proceeds from the upper 
angle of the uterus at first transversely outwards, and then down- 
wards, backwards, and inwards, so as to reach the neighborhood of 
the ovary. In the first part of its course it is straight, afterwards it 






62 



ORGANS CONCERNED IN PARTURITION. 



becomes flexuous and twisted on itself. It is contained in the upper 
part of the broad ligament, where it may be felt as a hard cord. It 
commences at the uterus by a narrow opening, admitting only the 
passage of a bristle, known as the ostium uterinum. As it passes 
through the muscular walls of the uterus the tube takes a somewhat 
curved, course, and opens into the uterine cavity by a dilated aper- 
ture. From its uterine attachment the tube expands gradually until 
it terminates in its trumpet-shaped extremity ; just before its distal 
end, however, it again contracts slightly. The ovarian end of the 
tube is surrounded by a number of remarkable fringe-like processes. 
These consist of longitudinal membranous fimbriae, surrounding the 
aperture of the tube, like the tentacles of a polyp, varying conside- 
rably in number and size, and having their edges cut and subdivided. 
On their inner surface are found both transverse and longitudinal 
folds of mucous membrane, continuous with those lining the tube 
itself (Fig. 29). One of these fimbriae is always larger and more de- 

Fig. 29. 




Fallopian Tube laid open (After Richard.) 

a, b. Uterine portion of Tube, c, d. Plicse of Mucous Membrane, e. Tubo-ovarian Ligaments and 

Fringes. /. Ovary, g. Round Ligaments. 

veloped than the rest, and is indirectly united to the surface of the 
ovary by a fold of peritoneum proceeding from its external surface. 
Its under surface is grooved so as to form a channel, open below. 
The function of this fringe-like structure is to grasp the ovary during 
the menstrual nisus ; and the fimbria which is attached to the ovan* 
would seem to guide the tentacles to the ovary which they are in- 
tended to seize. One or more supplementary series of fimbriae some- 
times exist, which have an aperture of communication with the canal 
of the Fallopian tube, beyond its ovarian extremity. 

Their Structure. — The lubes themselves consist of peritoneal, mus- 
cular, and mucous coats. The peritoneum surrounds the tube for 
three-fourths of its calibre, and comes into contact with the mucous 



THE FEMALE GENERATIVE ORGANS. 63 

lining at its fimbriated extremity, the only instance in the body 
where snch a junction occurs. The muscular coat is principally 
composed of circular fibres, with a few longitudinal fibres inter- 
spersed. Its muscular character has been doubted by Robin and 
Richard, but Farre had no difficulty in demonstrating the existence 
of muscular fibres, both in the human female and many of the lower 
animals. According to Robin the muscular tissue of the Fallopian 
tubes is entirely distinct from that of the uterus, from which he 
describes it as being separated by a distinct cellular septum. The 
mucous lining is thrown into a number of remarkable longitudinal 
folds, each of Avhich contains a dense and vascular fibrous septum, 
with small muscular fibres, and is covered with columnar and ciliated 
epithelium. The apposition of these produces a series of minute 
capillary tubes, along which the ovules are propelled, the action of 
the cilia, which is towards the uterus, apparently favoring their 
progress. 

The Ovaries. — The ovaries are the bodies in which the ovules are 
formed, and from which they are expelled, and the changes going on 
in them, in connection with the process of ovulation, during the 
whole period between the establishment of puberty and the cessation 
of menstruation, have an enormous influence on the female economy. 
Normally, the ovaries are two in number ; in some exceptional cases 
a supplementary ovary has been discovered ; or they may be entirely 
absent. They are placed in the posterior fold of the broad ligament, 
.usually below the brim of the pelvis, behind the Fallopian tubes, the 
left in front of the rectum, the right in front of some coils of the 
small intestine. Their situation varies, however, very much under 
different circumstances, so that they can scarcely be said to have a 
fixed and normal position. In pregnancy they rise into the abdomi- 
nal cavity with the enlarging uterus; and in certain conditions they 
are dislocated downwards into Douglas's space, where they may be 
felt through the vagina as rounded and very tender bodies. 

Their Connections. — The folds of the broad ligament, between which 
the ovaries are placed, form for them a kind of loose mesentery. 
Each of them is united to the upper angle of the uterus by a special 
ligament called the utero-ovarian. This is a rounded band of organic 
muscular fibres, about an inch in length, continuous with the super- 
ficial muscular fibres of the posterior wall of the uterus, and attached 
to the inner extremity of the ovary. It is surrounded by peritoneum, 
and through it the muscular fibres, which form an important integral 
part in the structure of the ovaries, are conveyed to them. The 
ovary is also attached to the fimbriated extremity of the Fallopian 
tube in the manner already described. 

The ovary is of an irregular oval shape (Fig. 30), the upper bor- 
der being convex, the lower — through which the vessels and nerves 
enter — being straight. The anterior surface, like that of tin 1 uterus, 
is less convex than the posterior. The outer extremity is more 
rounded and bulbous than the inner, which is somewhat pointed and 
eventually lost in its proper ligament. By these peculiarities l1 is 
possible to distinguish the left from the right ovary, after they Lave 



64 



ORGANS CONCERNED IN PARTURITION. 



been removed from the body. The ovary varies much in size under 
different circumstances. On an average, in adult life, it measures 
from one to two inches in length, three-quarters of an inch in width, 
and about half an inch in thickness. It increases greatly in size 
during each menstrual period ; a fact which has been demonstrated 
in certain cases of ovarian hernia, where the protruded ovary has 
been seen to swell as menstruation commenced ; also during preg- 
nancy, when it is said to be double its usual size. After the change of 
life it atrophies, and becomes rough and wrinkled on its surface. Be- 

Fig. 30. 




A A. Ovary enlarged under Menstrual IS T isus. b. Ripe Follicle projecting on its surface, a, a, a. 
Traces of previously ruptured Follicles. 



fore puberty, the surface of the ovary is smooth and polished, and of 
a whitish color. After menstruation commences, its surface becomes 
scarred by the rupture of the Graafian follicles (Fig. 30, A a), each 
of which leaves a little linear or striated cicatrix, of a brownish 
color ; and the older the patient the greater are the number of these 
cicatrices. 

Structure. — The structure of the ovary has been made the subject 
of many important observations. It has an external covering of 
epithelium, originally continuous with the peritoneum, called by 
some the germ-epithelium, in consequence of the ovules being formed 
from it in early foetal life. In the adult it is separated from the peri- 
toneum at the base of the organ by a circular white line, and it con- 
sists of columnar epithelium, differing only from the epithelium 
lining the Fallopian tubes, with which it is sometimes continuous 
through the attached fimbria uniting the tube and the ovary, in being 
destitute of cilia. Immediately beneath this covering is the dense 
coat known as the tunica albuginea, on account of its whitish color. 
It consists of short connective-tissue fibres, arranged in laminas, among 
which are interspersed fusiform muscular fibres. At the point where 
the vessels and nerves enter the ovary this membrane is raised into 
a ridge, which is continuous with the utero-ovarian ligament. The 




THE FEMALE GENERATIVE ORGANS. 65 

tunica albuginea is so intimately blended with the stroma of the 
ovary, as to be inseparable on dissection ; it does not, however, exist 
as a distinct lamina, bat is merely the external part of the proper 
structure of the ovary, in which more dense connective tissue is 
developed than elsewhere. 

The Stroma. — On making a longitudinal section of the ovary 
(Fig. 31). it will be seen to be composed of two parts, the more internal 
of which is of a reddish color from the num- 
ber of vessels that ramify in it, and is called Fig. 31 . 
the medullary or vascular zone ; while the 
external, of a whitish tint, receives the 
name of the cortical or parenchymatous 
substance. The former consists of loose 
connective tissue interspersed with elastic, 
and a considerable number of muscular 
fibres. According to Eouget 1 and His 2 
the muscular structure forms the greater 
part of the ovarian stroma. The latter de- 
scribes it as consisting essentially of inter- 
woven muscular fibres, which he terms T L a . , . ■ , 

. iin-p • 11 i i-ii i Longitudinal section of adult 

the "mSlIOrm tlSSUe, and WhlCh he be- ovary. (After Farre.) 

lieves to be continuous with the muscular 

layers of the ovarian vessels. The former believes that the mus- 
cular fasciculi accompany the vessels in the form of sheaths, as in 
erectile tissues. Both attribute to the muscular tissues an important 
influence in the expulsion of the ovules, and in the rupture of the 
Graafian follicles. Waldeyer and other writers, however, do not 
consider it to be so extensively developed as Eouget and His believe. 
The cortical substance is the more important, as that in which the 
Graafian follicles and ovules are formed. It consists of interlaced 
fibres of connective tissue, containing a large number of nuclei. The 
muscular fibres of the medullary substance do not seem to penetrate 
into it in man. In it are found the Graafian follicles, which exist in 
enormous numbers from the earliest periods of life, and in all stages 
of development (Fig. 32). 

Tlie Graafian Follicles. — According to the researches of Pfliiger, 
Waldeyer, and other German writers, the Graafian follicles are 
formed in early foetal life by cylindrical inflections of the epithelial 
covering of the ovary, which dip into the substance of the gland. 
These tubular filaments anastomose with each other, and in them 
are formed the ovules, which are originally the epithelial cells lining 
the tubes. Portions become shut off from the rest of the filaments, 
and form the Graafian follicles. The ovules, on this view, are highly 
developed epithelial cells, originally derived from the surface of the 
ovary, and not developed in its stroma. These tubular li laments 
disappear shortly after birth, but they have recently been detected 

1 Journal de Physiol, i. p. 787. 

2 Schultze's Arch. f. Mikrocop. Anat. 1865. 



66 



ORGANS CONCERNED IN PARTURITION. 



by Slavyansky 1 in the ovaries of a woman thirty years of age. 
These observations have been modified by Dr. Foulis, in a recent 



Fig. 32. 




Section through the Cortical part of the Ovary. 
s s. Ovarian Stromo. 1 1. Large-sized Graafian Follicles 



e. Surface Epithelium 
sizpd, and 3 3. Small-sized Graafian Follicles, o. Ovule within Graafian Follicle 
in the Stroma, g. Cells of the Membrana Granulosa. (After Turner.) 



2 2. Middle- 
D1). Bloodvessels 



Fig. 33. 




Vertical Section through the Ovary of the Human Foetus. 
g g. Germ-epithelium, with no. Developing Ovules in it. s s. Ovarian Stroma, containing ccc. 
Fusiform Connective Tissue Corpuscles, dd. Capillary Bloodvessels. In the centre of the Figure 
an Involution of the Germ-epithelium is shown; and at the left lower side a Primordial Ovule, with 
the Connective-tissue Corpuscles ranging themselves rouud it. (After Foulis.) 

graduation thesis, communicated to the Eoyal Society of Edinburgh. 2 
lie recognizes the origin of the ovules from the germ-epithelium 



1 Annales de Gynak, Feb. 1871. 

2 Proceedings of the Royal Soe. of Edinb., April, 1875. 



THE FEMALE GENERATIVE ORGANS. 



67 



covering the surface of the ovary, which is itself derived from the 
Wolffian body. He believes all the ovules to be formed from the 
germ-epithelium corpuscles, which become embedded in the stroma 
of the ovary, by the outgrowth of processes of vascular connective 
tissue, fresh germ-epithelial corpuscles being constantly produced on 
the surface of the organ up to the age of 2J years, to take the place 
of those already embedded in its stroma. lie believes the Graafian 
follicles to be formed by the growth of delicate processes of connec- 
tive tissue between and around the ovules, but not from tubular in- 
flections of the epithelium covering the gland, as described by 
Waldeyer (Fig. 33). 

The greater proportion of the Graafian follicles are only visible 
with the higher powers of the microscope, but those which are ap- 
proaching maturity are distinctly to be seen by the naked eye. The 
quantity of these follicles is immense. Foulis estimates that at birth 
each human ovary contains not less than 30,000. No fresh follicles 
appear to be formed after birth, and as development goes on some 
only grow, and by pressure on the others, destroy them. Of those 
that grow of course only a few ever reach maturity ; they are scat- 
tered through the substance of the ovary, some developing in the 
stroma, others on the surface of the organ, where they eventually 
burst, and are discharged into the Fallopian tube. 

Structure. — A ripe Graafian follicle has an external investing mem- 
brane (Fig. 34), which is generally described as consisting of two 

Fig. 34. 




Diagrammatic Section of Graafian Follicle. 
1. Ovum. 2. Membniiiii granulosa. '■'>. External membrane of Graafian follicle, t. Eta vessel* 



Ovarian stroma. 6. Cavity of Graafian follicle. 



External covering of ovary. 



distind layers; the external, or tunica fibrosa, highly vascular and 
formed of'connective tissue; the internal, or tunica />r>>/>ri'f, composed 
of young connective tissue, containing a large number of Fusiform 
or stellate cells, and numerous oil-globules. These layers, however, 

appear to be essentially formed of condensed ovarian str a. Within 

this capsule is the epithelial lining called the membrana granulosa, 
consisting of stratified columnar epithelial cells, which, according to 
Foulis, are originally formed from the nuclei of the Gbro-nuclear 



68 ORGANS CONCERNED IN PARTURITION. 

tissue of the stroma of the ovary. At one part of the circumference 
of the ovisac is situated the ovule, around which the epithelial cells 
are congregated in greater quantity, constituting the projection known 
as the discus proliger us. The remainder of the cavity of the follicle 
is filled with a small quantity of transparent fluid, the liquor folliculi, 
traversed by three or four minute bands, the retinacula of Barrj^, 
which are attached to the opposite walls of the follicular cavity, and 
apparently serve the purpose of suspending the ovule, and main- 
taining it in a proper position. In many young follicles this cavity 
does not at first exist, the follicle being entirely filled by the ovule. 
According to Waldeyer, the liquor folliculi is formed by the disinte- 
gration of the epithelial cells, the fluid thus produced collecting, and 
distending the interior of the follicle. 

Ovule. — The ovule is attached to some part of the internal surface 
of the Graafian follicle. It is a rounded vesicle about T i n of an inch 
in diameter, and is surrounded by a layer of columnar cells, distinct 
from those of the discus proligerus in which it lies. It is invested 
by a transparent elastic membrane, the zona pellucida, or vitelline 
membrane. In most of the lower animals the zona pellucida is per- 
forated by numerous very minute pores, only visible under the 
highest powers of the microscope ; in others there is a distinct aper- 
ture of a larger size, the micropyle, allowing the passage for the 
spermatozoa into the interior of the ovule. It is possible that similar 
apertures may exist in the human ovule, but they have not been 
demonstrated. Within the zona pellucida some embryologists de- 
scribe a second fine membrane, the existence of which has been 
denied by Bischoff. The cavity of the ovule is filled with a viscid 
yellow fluid, the yelk, containing numerous granules. It entirely 
fills the cavity, to the walls of which it is non-adherent. In the 
centre of the yelk in j^oung, and at some portion of its periphery in 
mature ovules, is situated the germinal vesicle, which is a clear cir- 
cular vesicle, refracting light strongly, and about g ! B th of a line in 
diameter. It contains a few granules, and a nucleolus, or germinal 
spot, which is sometimes double. 

From within outwards, therefore we find: — 

1. The germinal spot; round this 

2. The germinal vesicle, contained in 

3. The yelk, which is surrounded by the 

4. Zona pellucida, with its layers of columnar epithelial cells. 
These constitute the ovule. 

The ovule is contained in — 

The Graafian follicle, and lies in that part of its epithelial lining 
called the — 

Discus proligerous, the rest of the follicle being occupied by the 
liquor folliculi. Bound these we have the epithelial lining or mem- 
brana granulosa, and the external coat consisting of the tunica pro- 
pria and the tunica fibrosa. 

Vessels and Nerves of the Ovary. — The vascular supply of the ovary 
is complex. The arteries enter at the hilum, penetrating the stroma 
in a spiral curve, and are ultimate!}?- distributed in a rich capillary 



THE FEMALE GENERATIVE ORGANS 



69 



plexus to the follicles. The large veins unite freely with each other, 
and form a vascular and erectile plexus, continuous with that sur- 
rounding the uterus, called the bulb of the ovarj (Fig. 35). Lym- 
phatics and nerves exist, but their mode of termination is unknown. 



Fig. 35. 




u. Uterus 
Pampiniform ovarian plexus 



Bulb of Ovary. 
Ovary and utero-ovarian ligament, r. Fallopian tube. 



1. Utero-ovarian vein. 



3. Commencement of spermatic vein. 



The Mammary Glands. — To complete the consideration of the 
generative organs of the female we must study the mammary glands, 
which secrete the fluid destined to nourish the child. In the human 
subject they are two in number, and instead of being placed upon the 
abdomen, as in most animals, they are situated on either side of the 
sternum, over the pectoralis major muscles, and extend from the third 
to the sixth ribs. This position of the glands is obviously intended 
to suit the erect position of the female in suckling. They are con- 
vex anteriorly, and flattened posteriorly where they rest on the 
muscles. They vary greatly in size in different subjects, chiefly in 
proportion to the amount of adipose tissue they contain. In man. 
and in girls, previous to puberty, they are rudimentary in structure ; 
while in pregnant women they increase greatly in size, the true 
glandular structures becoming much hypertrophied. Anomalies in 
shape and position are sometimes observed. Supplementary mammae, 
one or more in number, situated on the upper portion of the mam- 
mae, are sometimes met with, identical in structure with the normally 
situated glands; or, more commonly, an extra nipple is observed 1>\ 
the side of the normal one. In some races, especially the African, 
the mamm;c are so enormously developed, that the mother is able to 
suckle her child over her shoulder. 

Their Structure. — The skin covering the gland is sofl and supple, 
and during pregnancy often becomes covered with fine white lines, 
while large blue veins may be observed coursing over. Underneath 
it is a quantity of connective tissue, containing a <■< >nsiderable amounl 
of fat, which extends between the true glandular structure. 'This is 
composed of from fifteen to twenty lobes, each of which is formed 
of a number of lobules. The lobules arc produced by the agg 
tion of the terminal acini in which the milk is formed. The acini 
are minute cul-de-sacs opening into little ducts, which unite with 



TO ORGANS CONCERNED IN PARTURITION. 

each other until they form a large duct for each lobule ; the ducts of 
each lobule unite with each other, until they end in a still larger duct 
common to each of the fifteen or twenty lobes into which the gland 
is divided, and eventually open on the surface of the nipple. These 
terminal canals are known as the yalactophorous ducts (Fig. 36). 
They become widely dilated as they approach the nipple, so as to 
form reservoirs in which milk is stored until it is required, but when 
they actually enter the nipple they again contract. Sometimes they 
give off lateral branches, but, according to Sappey, they do not anas- 
tomose with each other, as some anatomists have described. These 
excretory ducts are composed of connective tissue, with numerous 
elastic fibres on their external surface. Sappey and Eobin describe 
a layer of muscular fibres, chiefly developed near their terminal 
extremities. They are lined with columnar epithelium, continuous 
with that in the acini ; and it is by the distension of its cells with 
fatty matter, and their subsequent bursting, that the milk is formed. 
Nipple. — The nipple is the conical projection at the summit of the 
mamma, and it varies in size in different women. Not very unfre- 
quently, from the continuous pressure to which it has been subjected 
by the dress, it is so depressed below the surface of the skin as to 
prevent lactation. It is generally larger in married than in single 
women, and increases in size during pregnancy. Its surface is covered 
with numerous papillae, giving it a rugous aspect, and at their bases 
the orifices of the lactiferous ducts open. Here are also the openings 
of numerous sebaceous follicles, which secrete an unctuous material 
supposed to protect and soften the integument during lactation. 
Beneath the skin are muscular fibres, mixed with connective and 

Fig. 36. 




1. Galactophorous ducts. 2. Lobuli of the mammary gland. 

clastic tissues, vessels,' nerves, and lymphatics. When the nipple is 
irritated it contracts and hardens, and by some this is attributed to 
its erectile properties. The vascularity, however, is not great, and 
it contains no true erectile tissue : the hardening is, therefore, due 
to muscular contraction. Surrounding the nipple is the areola, of a 
pink color in virgins, becoming dark from the development of pig- 
ment cells during pregnancy, and always remaining somewhat dark 
after childbearing. On its surface are a number of prominent tuber- 



OVULATION AND MENSTRUATION. 71 

cles, sixteen to twenty in number, which, also become largely de- 
veloped during gestation. They are supposed by some to secrete 
milk, and to open into the lactiferous tubes; most probably they are 
composed of sebaceous glands only. Beneath the areolar is a circular 
band of muscular fibres, the object of which is to compress the lactif- 
erous tubes which run through it, and thus to favor the expulsion 
of their contents. The mammas receive their blood from the internal 
mammary aud intercostal arteries, and they are richly supplied with 
lymphatic vessels, which open into the axillary glands. The nerves 
are derived from the intercostal and thoracic branches of the brachial 
plexus. 

The secretion of milk in women who are nursing is accompanied 
by a peculiar sensation, as if milk were rushing into the breast. 
called the "draught," which is excited by the efforts of the child to 
suck, and by various other causes. The sympathetic relations be- 
tween the mammas and the uterus are very well marked, as is shown 
in the unimpregnated state by the fact of the frequent occurrence of 
sympathetic pains in the breast in connection with various uterine 
diseases, and, after delivery, by the well-known fact that suction pro- 
daces reflex contraction of the uterus, and even severe after-pains. 



CHAPTEK III. 

OVULATION AND MENSTRUATION. 

Functions of the Ovary. — The main function of the ovary is to 
supply the female generative element, and to expel it, when ready 
for impregnation, into the Fallopian tube, along which it passes into 
the uterus. This process takes place spontaneously in all viviparous 
animals, and without the assistance of the male. In the lower animals 
this periodical discharge receives the name of the oestrus or rut, at 
which time only the female is capable of impregnation and admits 
the approach of the male. In the human female the periodical dis- 
charge of the ovule, in all probability, takes place in connection with 
menstruation, which may therefore be considered to he the, analogue 
of the rut in animals. After each menstrual period Graafian folli- 
cles undergo change- which prepare them for rupture and the dis- 
charge of their contained ovules. After rupture, certain changes 
occur which have for their objed the healing of the rent in the 
ovarian tissue through which the ovule has escaped, and the filling 
up of the cavity in which it was contained. This results in the for- 
mation of a peculiar body in the substance of the ovary, called the 
corpus luteum which is essentially modified should pregnancy occur, 



72 ORGANS CONCERNED IN PARTURITION. 

arid is of great interest and importance. During the whole of the 
childbearing epoch the periodical maturation and rupture of the 
Graafian follicles are going on. If impregnation does not take place, 
the ovules are discharged and lost ; if it does, ovulation is stopped, 
as a general rule, during gestation and lactation. 

Theory of Menstruation. — This, broadly speaking, is an outline of 
the modern theory of menstruation which was first broached in the 
year 1821 by Dr. Power, and subsequently elaborated by Negrier, 
Bischoff, Kaciborski, and many other writers. Although the se- 
quence of events here indicated may be taken to be the rule, it must 
be remembered that it is one subject to many exceptions, for un- 
doubtedly ovulation may occur without its outward manifestation, 
menstruation, as in cases in which impregnation takes place during 
lactation or before menstruation has been established, of which many 
examples are recorded. These exceptions have led some modern 
writers to deny the ovular theory of menstruation, and their vieAVS 
will require subsequent consideration. 

In order to understand the subject properly it will be necessary to 
study the sequence of events in detail. 

Changes in the Graafian Follicle. — The changes in the Graafian 
follicle which are associated with the discharge of the ovules com- 
prise — 1. Maturation. As the period of puberty approaches a cer- 
tain number of the Graafian follicles, fifteen to twenty in number, 
increase in size, and come near the surface of the ovary. Amongst 
these one becomes especially developed, preparatory to rupture, and 
upon it for the time being all the vital energy of the ovary seems to 
be concentrated. A similar change in one, sometimes in more than 
one, follicle takes place periodically during the whole of the child- 
bearing epoch, in connection with each menstrual period, and an 
examination of the ovary will show several follicles in different stages 
of development. The maturing follicle becomes gradually larger, 
until it forms a projection on the surface of the ovary, from five to 
seven lines in breadth, but sometimes even as large as a nut (Fig. 
30). This growth is due to the distension of the follicle by the in- 
crease of its contained fluid, which causes it so to press upon the 
ovarian structures covering it, that they become thinned, separated 
from each other, and partially absorbed, until they eventually readily 
lacerate. The follicle also becomes greatly congested, the capillaries 
coursing over it becomes increased in size and loaded with blood, 
and being seen through the attenuated ovarian tissue, give it, when 
mature, a bright red color. At this time some of these distended 
capillaries in its inner coat lacerate, and a certain quantity of blood 
escapes into its cavity. This escape of blood takes place before 
rupture, and seems to have for its principal object the increase of the 
tension of the follicle, of which it has been termed the menstruation. 
Pouchet was of opinion that the blood collects behind the ovule, and 
carries it up to the surface of the follicle. By these means the follicle 
is more and more distended, until at last it ruptures either sponta- 
neously or, it may be, under the stimulus of sexual excitement. 
Whether the laceration takes place during, before, or after the men- 



OVULATION AND MENSTRUATION. 73 

strual discharge is not yet positively known : from the results of 
post-mortem examination in a number of women who died shortly 
before or after the period, Williams believes that the ovules are ex- 
pelled before the monthly flow commences. 1 In order that the ovule 
may escape, the laceration must, of course, involve not only the coats 
of the Graafian follicles, but also the superincumbent structures. 

Laceration seems to be aided by the growth of the internal layer 
of the follicle, which increases in thickness before rupture, and 
assumes a characteristic yellow color from the number of oil-globules 
it then contains. It is also greatly facilitated, if it be not actually 
produced, by the turgescence of the ovary at each menstrual period, 
and by the contraction of the muscular fibres in the ovarian stroma. 
As soon as the rent in the follicular walls is produced, the ovule is 
discharged, surrounded by some of the cells of the membrana granu- 
losa, and is received into the fimbriated extremity of the Fallopian 
tube, which grasps the ovary over the site of the rupture. By the 
vibratile cilia of its epithelial lining, it is then conducted into the 
canal of the tube, along which it is propelled, partly by ciliary action 
and partly by muscular contraction in the walls of the tube. 

Obliteration of the Graafian Follicle. — After the ovule has escaped, 
certain characteristic changes occur in the empty Graafian follicle, 
which have for their object its cicatrization and obliteration. There 
are great differences in the changes which occur when impregnation 
has followed the escape of the ovule, and they are then so remarkable 
that they have been considered certain signs of pregnancy. They 
are, however, differences of degree rather than of kind. It will be 
well, however, to discuss them separately. 

CJianges undergone by the Follicle where Impregnation does not occur, 
— As soon as the ovule is discharged, the edges of the rent through 
which it has escaped become agglutinated by exudation, and the fol- 
licle shrinks, as is generally believed, by the inherent elasticity of its 
internal coat, but according to Kobin, who denies the existence of 
this coat, from compression by the muscular fibres of the ovarian 
stroma. In proportion to the contraction that takes place, the inner 
layer of the follicle, the cells of which have become greatly hyper- 
trophied and loaded with fat granules previous to rupture, is thrown 
into numerous folds. The greater the amount of contraction the 
deeper these folds become, giving to a section of the follicle an 
appearance similar to that of the convolutions of the brain (Fig. 37). 
These folds in the human subject are generally of a brignl yellow 
color, but in some of the mammalia they are of a deep red. The tinl 
was formerly ascribed by Raciborski to absorption of the coloring 
matter of the blood-clot contained in the follicular cavity, a theory 
he has more recently abandoned in favor of tin* view maintained 
by Coste that it is due to the inherent color of the cells of the lining 
membrane of the follicle, which, though not well marked in a single 
cell, becomes very apparent en masse. The existence of ;t contained 
blood-clot is also denied by the latter physiologist, except as an 

1 Proceedings of the Royal Society, 1S75. 



74 



ORGANS CONCERNED IN PARTURITION. 




Section of ovary, showing corpus lute 

urn three weeks after menstruation. 

(After Dalton.) 



unusual pathological condition ; and he describes the cavity as contain- 
ing a gelatinous and plastic fluid, which becomes absorbed as contrac- 
tion advances. The folds into which the membrane has been thrown 

continue to increase in size, from the 
proliferation of their cells, until they 
unite and become adherent, and eventu- 
ally fill the follicular cavity. By the 
time that another Graafian follicle is 
matured and ready for rupture the 
diminution has advanced considerably, 
and the empty ovisac is reduced to a 
very small size. The cavity is now 
nearly obliterated, the yellow color of 
the convolutions is altered into a whitish 
tint, and on section the corpus luteum 
has the appearance of a compact white 
stellate cicatrix, which generally disap- 
pears in less than forty days from the 
period of rupture. The tissue of the 
ovary at the site of laceration also 
shrinks, and this, aided by the contrac- 
tion of the follicle, gives rise to one of those permanent pits or 
depressions which mark the surface of the adult ovary. Slavy- 
ansky 1 has recently shown that only a few of the immense number 
of Graafian follicles undergo these alterations. The greater propor- 
tion of them seem never to discharge their ovules, but, after increas- 
ing in size, undergo retrogressive changes exactly similar in their 
nature, but to a much less extent, to those which result in the for- 
mation of a corpus luteum. The sites of these may afterwards be 
seen as minute striae in the substance of the ovary. 

Changes undergone by the Follicle vjhen Impregnation has taken 
place. — Should pregnancy occur, ail the changes above described take 
place, but, inasmuch as the ovary partakes of the stimulus to which 
all the generative organs are then subjected, they are much more 
marked and apparent. Instead of contracting and disappearing in a 
few weeks, the corpus luteum continues to grow until the third or 
fourth month of pregnancy ; the folds of the inner layer of the ovisac 
become large and fleshy, and permeated by numerous capillaries, and 
ultimately become so firmly united that the margins of the convolu- 
tions thin and disappear, leaving only a firm fleshy yellow mass, 
averaging from 1 to 1 J inches in thickness, which surrounds a central 
cavity, often containing a whitish fibrillated structure, believed to 
be the remains of a central blood clot. This was erroneously sup- 
posed by Montgomer}^ to be the inner layer of the follicle itself, and 
he conceived the yellow substance to be a new formation between it 
and the external layer, while Robert Lee thought it was placed 
external to both the external and internal layers. 

Between the third and fourth months of pregnancy, when the 



1 Archiv do Phys. March, 1874. 



OVULATION AND MENSTRUATION. 



75 



corpus luteum has attained its maximum of development (Fig. 38), 
it forms a firm projection on the surface of the ovary, averaging 
about 1 inch in length, and rather more than \ an inch in breadth . 
After this it commences to atrophy (Fig. 39), the fat-cells become 



Fig. 38. 



Fig. 39. 





Corpus luteum at the fourth month of pregnancy. 
(After Dalton.) 



Corpus luteum of pregnancy at 
term. (After Dalton.) 



absorbed, and the capillaries disappear. Cicatrization is not com- 
plete until from one to two months after delivery. 

Its Value as a Sign of Pregnancy. — On account of the marked 
appearance of the corpus luteum it was formerly considered to be an 
infallible sign of pregnancy ; arid it was distinguished from the cor- 
pus luteum of the nonpregnant state by being called a "true" as 
opposed to a "false" corpus luteum. From what has been said it 
will be obvious that this designation is essentially wrong, as the 
difference is one of degree only. Nor do obstetricians attach by any 
means the same importance as they did formerly to its presence as 
indicating impregnation; for even when well marked, other and 
more reliable signs of recent delivery, such as enlargement of the 
uterus, are sure to be present, especially at the time when it has 
reached its maximum of development; while after delivery at term 
it has no longer a sufficiently characteristic appearance to be depended 
on. 

Menstruation. — By the term menstruation (catamenia, periods, etc.), 
is meant the periodical discharge of blood from the uterus, which 
occurs, in the healthy woman, every lunar month, except during 
pregnancy and lactation, when it is, as a rule, suspended. 

Period of Establishment. — The first appearance of menstruation 
coincides with the establishment of puberty, and the physical changes 
that accompany it indicate that the female is capable of conception 
and childbearing, although exceptional cases are recorded in which 
pregnancy occurred before menstruation had begun. In temperate 
climates it generally commences between the 1 Ith and L 6th years, 
the largest number of cases being met with in the L5th year. This 



76 ORGANS CONCERNED IN PARTURITION. 

rule is subject to many exceptions, it being by no means very rare 
for menstruation to become established as early as the 10th or 11th 
years, or to be delayed until the 18th or 20th. Beyond these physio- 
logical limits a few cases are from time to time met with in which it 
has begun in early infancy, or not until a comparatively late period 
of life. 

Influence of Climate, Race, etc. — Various accidental circumstances 
have much, to do with its establishment. As a rule, it occurs some- 
what earlier in tropical, and later in very cold, than in temperate cli- 
mates. The influence of climate has been unduly exaggerated. It 
used to be generally stated that in the Arctic regions women did not 
menstruate until they were of mature age, and that in the tropics 
girls of 10 or 12 years of age did so habitually. The researches of 
Koberton, of Manchester, 1 first showed that the generally received 
opinions were erroneous ; and the collection of a large number of 
statistics has corroborated his opinion. There can be no doubt, how- 
ever, that a larger proportion of girls menstruate early in warm cli- 
mates. Joulin found that in tropical climates, out of 1635 cases, the 
largest proportion began to menstruate between the 12th and 13th 
years ; so that there is an average difference of more than two years 
between the period of its establishment in the tropics and in temper- 
ate countries. Harris 2 states that among the Hindoos 1 to 2 per cent, 
menstruate as early as nine years of age ; 3 to 4 per cent, at ten ; 8 
per cent, at eleven ; and 25 per cent, at twelve ; while in London or 
Paris probably not more than one girl in 1000 or 1200 does so at 
nine years. The converse holds true with regard to cold climates, 
although we are not in possession of a sufficient number of accurate 
statistics to draw very reliable conclusions on this point ; but out of 
4715 cases, including returns from Denmark, Norway and Sweden, Eus- 
sia and Labrador, it was found that menstruation was established on 
an average a year later than in more temperate countries. It is prob- 
able that the mere influence of temperature has much to do in produc- 
ing these differences, but there are other factors, the action of which 
must not be overlooked. Eaciborski attributes considerable import- 
ance to the effect of race ; and he has quoted Dr. Webb, of Calcutta, 
to the effect that English girls in India, although subjected to the 
same climatic influence as the Indian races, do not, as a rule, men- 
struate earlier than in England ; while in Austria, girls of the Magyar 
race menstruate considerably later than those of German parentage. 3 
The surroundings of girls, and their manner of education and living, 
have probably also a marked influence in promoting or retarding its 
establishment. Thus, it will commence earlier in the children of the 
rich, who are likely to have a highly developed nervous organization, 
and are habituated to luxurious living, and a premature stimulation 
of the mental faculties by novel-reading, society, and the like ; while 
amongst the hard- worked poor, or in girls brought up in the country, 

1 Edin. Med. and Surg. Journ., 18." 2. 

2 Amor. Journ. of Obst. 1871. R- P- Harris, on early puberty. 

3 Op. eit,, p. 227. 



OVULATION AND MENSTRUATION . 77 

it is more likely to begin later. Premature sexual excitement is said 
also to favor its early appearance, and the influence of this among 
the factory girls of Manchester, who are exposed in the course of 
their work to the temptations arising from the promiscuous mixing 
of the sexes, has been pointed out by Dr. Clay. 1 

Changes Occurring at Puberty. — The first appearance of menstrua- 
tion is accompanied by certain well-marked changes in the female 
system, on the occurrence of which we say that the girl has arrived 
at the period of puberty. The pubes become covered with hair, the 
breasts enlarge, the pelvis assumes its fully-developed form, and the 
general contour of the body fills out. The mental qualities also alter ; 
the girl becomes more shy and retiring, and her whole bearing indi- 
cates the change that has taken place. The menstrual discharge is 
not established regularly at once. For one or two months there may 
be only premonitory symptoms : a vague sense of discomfort, pains 
in the breasts, and a feeling of weight and heat in the back and loins. 
There then may be a discharge of mucus tinged with blood, or of 
pure blood, and this may not again show itself for several months. 
Such irregularities are of little consequence on the first establishment 
of the function, and need give rise to no apprehension. 

Period of Duration and Recurrence. — As a rule, the discharge re- 
curs every twenty-eight days, and with some women with such regu- 
larity that they can foretell its appearance almost to the hour. The 
rule is, however, subject to very great variations. It is by no means 
uncommon, and strictly within the limits of health, for it to appear 
every twentieth day, or even with less interval ; while, in other cases, 
as much as six weeks may habitually intervene between two periods. 
The period of recurrence may also vary in the same subject. I am 
acquainted with patients who sometimes have only twenty-eight days, 
at others as many as forty-eight days, between their periods, without 
their health in any way suffering. Joulin mentions the case of a lady 
who only menstruated two or three times in the year, and whose 
sister had the same peculiarity. 

The duration of the period varies in different women, and in the 
same woman at different times. In this country its average is four 
or five days, while in France Dubois and Brierre de Boismonl fix 
eight days as the most usual length. Some women arc only unwell 
for a few hours, while in others the period may last many days 
beyond the average without being considered abnormal. 

Quantity of Blood lost. — The quantity of blood lost varies in dif- 
ferent women. Hippocrates puts it at 3xviij, which, however. Is 
much too high an estimate. Arthur Farre thinks thai from .si.j t<> 
■£iij is the full amount of a healthy peri' »d, and thai the quantity 
cannot habitually exceed this withoul producing serious constitu- 
tional effects. Rich diet, Luxurious living, and anything that un- 
healthily stimulates the body and mind, will have an injurious eflfed 
in increasing the flow, which is. therefore, less in hard-worked 
countrywomen than in the better classes and residents in towns. 

1 Brit. Record of' Obst. Med., vol. i. 



T8 ORGANS CONCERNED IN PARTURITION. 

It is more abundant in warm climates, and our countrywomen in 
India "habitually menstruate over-profusely, becoming less abundantly 
unwell when they return to England. [The same may be said of our 
Northern women when residing in the Gulf States, and of many natives 
of those States, who improve materially by removing to the Lake 
States. — Ed.] Some women appear to menstruate more in summer 
than in winter. I am acquainted with a lady who spends the winter 
in St. Petersburg, where her periods last eight or ten daj^s, and the 
summer in England, where they never exceed four or five. The 
difference is probably due to the effect of the over-heated rooms in 
which she lives in Eussia. 

The daily loss is not the same during the continuance of the period. 
It generally is at first slight, and gradually increases so as to be most 
profuse on the second or third day, and as gradually diminishes. To- 
wards the last days it sometimes disappears for a few hours, and 
then comes on again, and is apt to recur under any excitement or 
emotion. 

Quality of Menstrual Blood. — As the menstrual fluid escapes from 
the uterus it consists of pure blood, and, if collected through the 
speculum, it coagulates. The ordinary menstrual fluid does not 
coagulate unless it is excessive in amount. Various explanations of 
this fact have been given. It was formerly supposed either to contain 
no fibrine, or an unusually small amount. Eetzius attributes its 
non-coagulation to the presence of free lactic and phosphoric acids. 
The true explanation was first given by Mandl, who proved that 
even small quantities of pus or mucus in blood were sufficient to 
keep the fibrine in solution; and mucus is always present to greater 
or less amount in the secretions of the cervix and vagina, which mix 
with the menstrual blood in its passage through the genital tract. 
If the amount of blood be excessive, however, the mucus present is 
insufficient in quantity to produce this effect, and coagula are then 
formed. 

On microscopic examination the menstrual fluid exhibits blood 
corpuscles, mucous corpuscles, and a considerable amount of epithelial 
scales, the last being the debris of the epithelium lining the uterine 
cavity. According to Virchow the form of the epithelium often 
proves that it comes from the interior of the utricular glands. The 
color of the blood is at first dark, and as the period progresses it 
generally becomes lighter in tint. In women who are in bad health 
it is often very pale. These differences doubtless depend upon the 
amount of mucus mingled with it. The menstrual blood has always 
a characteristic, faint, and heavy odor, which is analogous to that 
which is so distinct in the lower animals during the rut. Eaciborski 
mentions a lady who was so sensitive to this odor that she could 
always tell to a certainty when" any woman was menstruating. It 
is attributed either to decomposing mucus mixed with the blood, 
which, when partially absorbed, may cause the peculiar odor of the 
breath often perceptible in menstruating women; or to the mixture 
with the fluid of the sebaceous secretion from the glands of the vulva. 
It probably gave rise to the old and prevalent prejudices as to the 



OVULATION AND MENSTRUATION. 79 

deleterious properties of menstrual blood, which, it is needless to say, 
are altogether without foundation. 

Source of the Blood. — It is now universally admitted that the source 
of the menstrual blood is the mucous membrane lining the interior 
of the uterus, for the blood ma}" be seen oozing through the os uteri 
by means of the speculum, and in cases of prolapsus uteri ; while in 
cases of inverted uterus it may be actually observed escaping from 
the exposed mucous membrane, and collecting in minute drops upon 
its surface. During the menstrual nisus the whole mucous lining 
becomes congested to such an extent that, in examining the bodies 
of women who have died during menstruation, it is found to be 
thicker, larger, and thrown into folds, so as to completely fill the 
uterine cavity. The capillary circulation at this time becomes very 
marked, and the mucous membrane assumes a deep red hue, the net- 
work of capillaries surrounding the orifices of the utricular glands 
being especially distinct. These facts have an unquestionable con- 
nection with the production of the discharge, but there is much diffe- 
rence of opinion as to the precise mode in which the blood escapes 
from the vessels. Coste believed that the blood transudes through 
the coats of the capillaries without any laceration of their structure. 
Farre inclines to the hypothesis that the uterine capillaries terminate 
by open mouths, the escape of blood through these, between the 
menstrual periods, being prevented by muscular contraction of the 
uterine walls. Pouchet believed that during each menstrual epoch 
the entire mucous membrane is broken down and cast off in the form 
of minute shreds, a fresh mucous membrane being developed in the 
interval between two periods. During this process the capillary net- 
work would be laid bare and ruptured, and the escape of blood 
readily accounted for. Tyler Smith, who adopted this theory, states 
that he has frequently seen the uterine mucous membrane, in women 
who have died during menstruation, in a state of dissolution, with 
the broken loops of the capillaries exposed. The phenomena at- 
tending the so-called membranous dj^smenorrhoea, in which the 
mucous membrane is thrown off* in shreds, or as a cast of the uterine 
cavity — the nature of which was first pointed out by Simpson and 
Oldham — have been supposed to corroborate this theory. This view- 
is, in the main, corroborated by the recent researches of Engelman, 
Williams, 1 and others. Williams describes the mucous lining of the 
uterus as undergoing a Catty degeneration before cadi period, which 
commences near the inner os, and extends over the whole mucous 
membrane, and down to the muscular wall. This seems to bring on 
a certain amount of muscular contraction, which drives the blood 
into the capillaries of the mucosa, and these, having become degene- 
rated, rca<lily rupture, and permit the escape of the blood. The 
mucous membrane now rapidly disintegrates, and is casl off in shreds 
with the menstrual discharge, in which masses of epithelial cells may 
always be detected. A.s soon as the period i> over the formation of 
a new mucous membrane is begun, from proliferation of the elements 

1 On the Structure of the Mucous Membrane of the Uterus, Obst. Journ., 1875. 



80 ORGANS CONCERNED IN PARTURITION. 

of the muscular coat, and at the end of a week the whole uterine 
cavity is lined by a thin mucous membrane. This grows until the 
advent of another period, when the same degenerative changes occur 
unless impregnation has taken place, in which case it becomes further 
developed into the decidua. 

Theory of Menstruation. — That there is an intimate connection be- 
tween ovulation and menstruation is admitted by most physiologists, 
and it is held by many that the determining cause of the discharge 
is the periodic maturation of the Graafian follicles. There is abundant 
evidence of this connection, for we know that when, at the change 
of life, the Graafian follicles cease to develop, menstruation is arrested; 
and when the ovaries are removed by operation, of which there are 
now numerous cases on record, or when they are congenitally absent, 
menstruation does not take place. A few cases, however, have been 
observed in which menstruation continued after double ovariotomy, 
and these have been used as an argument by those physiologists who 
doubt the ovular theory of menstruation. Slavyansky has particu- 
larly insisted on such cases, which, however, are probably susceptible 
of explanation. It may be that the habit of menstruation may con- 
tinue for a time even after the removal of the ovaries, and it has not 
been shown that menstruation has continued permanently after double 
ovariotomy, although it certainly has occasionally, although quite 
exceptionally, done so for a time. It is possible, also, that, in such 
cases, a small portion of ovarian tissue may have been left unre- 
moved, sufficient to carry on ovulation. Eoberts, a traveller quoted 
by Depaul and Gueniot in their article on Menstruation in the "Dic- 
tionnaire des Sciences Me'dicales," relates that in certain parts of 
Central Asia it is the custom to remove both ovaries in young girls 
who act as guards to the harems. These women, known as hedjeras, 
subsequently assume much of the virile type, and never menstruate. 
The same close connection between ovulation and the rut of animals 
is observed, and supports the conclusion that the rut and menstrua- 
tion are analogous. The chief difference between ovulation in man 
and the lower animals is that in the latter the process is not generally 
accompanied by a sanguineous flow. To this there are exceptions, 
for in monkeys there is certainly a discharge analogous to menstrua- 
tion occurring at intervals. Another point of distinction is that in 
animals connection never takes place except during the rut, and that 
it is then only that the female is capable of conception ; while in 
the human race conception only occurs in the interval between the 
periods. This is another argument brought against the ovular theory, 
because, it is said, if menstruation depend on the rupture of a Graafian 
follicle and the emission of an ovule, then impregnation should only 
take place during or immediately after menstruation. Coste explains 
this by supposing that it is the maturation and not the rupture of the 
follicle which determines the occurrence of menstruation ; and that 
the follicle may remain unruptured for a considerable time after it is 
mature, the escape of the ovule being subsequently determined by 
some accidental cause, such as sexual excitement. However this 
may be, there is good reason to believe that the susceptibility to con- 



OVULATION AXD MENSTRUATION. 81 

ception is greater during the menstrual epochs. Eaciborski believes 
that in the large proportion of cases impregnation occurs in the first 
half of the menstrual interval, or in the few da}'s immediately pre- 
ceding the appearance of the discharge. There are, however, very 
numerous exceptions, for in Jewesses, who almost invariably live 
apart from their husbands for eight days after the cessation of men- 
struation, impregnation must constantly occur at some other period 
of the interval, and it is certain that they are not less prolific than 
other people. This rule with them is very strictly adhered to, as 
will be seen by the accompanying interesting letter from a medical 
friend who is a well-known member of that community, and which 
I have permission to publish. 1 This fact is of itself sufficient to 
disprove the theory advanced by Dr. Avrard, 2 that impregnation is 
impossible in the latter half of the menstrual interval. This, and 
the other reasons referred to, undoubtedly throw some doubt on the 
ovular theory, but they do not seem to be sufficient to justif}^ the 
conclusion that menstruation is a physiological process altogether 
independent of the development and maturation of the Graafian 
follicles. All that they can be fairly held to prove is that the escape 
of the ovules may occur independently of menstruation, but the 
weight of evidence remains strongly in favor of the theory which is 
generally received. 

1 10 Bernard Street, Russell Square, July 28, 1873. 

My dear Sir. 

1. To the best of my knowledge and belief, the law which prohibits sexual 
intercourse amongst Jews for seven clear days after the cessation of menstruation, is 
almost universally observed ; the exceptions not being sufficient to vitiate statistics. 
The law has perhaps fewer exceptions on the Continent — especially Russia and 
Poland, where the Jewish population is very great— than in England. Even here. 
however, women who observe no other ceremonial law observe this, and cling to it 
after everything else is tin-own overboard. There are doubtless many exceptions, 
especially among the better classes in England, who keep only three days after the 
cessation of the menses. 

2. The law is — as you state — that should the discharge last only an hour or so, or 
should there be only one gush or one spot on the linen, the five days during which 
the period might continue are observed : to which must be superadded the Beven clear 
days = twelve days per mensem in which connection is disallowed. Should any dis- 
charge be seen in the intermenstrual period, seven days would have to be kept, but 
not the five, for such irregular discharge. 

S. The "bath of purification." which must contain at least eighty gallons, is used 
on the last night of the seven clear days. It is not used till after a bath for cleansing 
purposes; and. from the night when BUch •" purifying" hath is used, Jewish women 
are accustomed to calculate the commencement of pregnancy. That you should not 

have heard of it is not strange ; its mention would he considered highly indelicate. 

4. Jewish women reckon their pregnancy to last nine calendar or ten lunar months, 

270 to 280 days. There are no special data on which to reckon an average, nor do 

I know of an_\- hooks on the subject, except Borne Talmudic authorities which I will 

look up for you if you desire it. Pray make no apologies tor writing to me: an\ 
information I possess is at your service. 

I am, dear Sir, vours verv truly, 

Dr. Playfair. ' A. Ajshrb. 

P.S. The Biblical foundation for the law of the seven clear days is Leviticus w.. 

verse 19 till the end of the chapter — especially \er>e 28. 

2 Rev. de Therap. Med. Chir. 18G7. 



82 ORGANS CONCERNED IN PARTURITION. 

Purpose of the Menstrual Loss. — The cause of the monthly perio- 
dicity is quite unknown, and will probably always remain so. The 
purpose of the loss of so much blood is also somewhat obscure. To 
a certain extent it must be considered an accident or complication 
of ovulation, produced by the vascular turgescence. Nor is it essen- 
tial to fecundation, because women often conceive during lactation, 
when menstruation is suspended; or before the function has become 
established. It may, however, serve the negative purpose of relieving 
the congested uterine capillaries which are periodically filled with a 
supply of blood for the great growth which takes place when concep- 
tion has occurred. Thus immediately before each period the uterus 
may be considered to be placed by the afflux of blood in a state ot 
preparation for the function it may be suddenly called upon to per- 
form. That the discharge relieves a state of vascular tension which 
accompanies ovulation is proved by the singular phenomenon of 
vicarious menstruation, which is occasionally, though rarely, met 
with. It occurs in cases in which, from some unexplained cause, 
the discharge does not escape from the uterine mucous membrane. 
Under such circumstances a more or less regular escape of blood may 
take place from other sites. The most common situations are the 
mucous membranes of the stomach, of the nasal cavities, or of the 
lungs; the skin, not uncommonly that of the mammae, probably on 
account of their intimate sympathetic relation with the uterine organs; 
from the surface of an ulcer; or from hemorrhoids. It is a note- 
worthy fact that in all these cases the discharge occurs in situations 
where its external escape can readily take place. This strange 
deviation of the menstrual discharge may be taken as a sign of 
general ill-health, and it is usually met with in delicate young women 
of highly mobile nervous constitution. It may, however, begin at 
puberty, and it has even been observed during the whole sexual life. 
The recurrence is regular, and always in connection with the men- 
strual nisus, although the amount of blood lost is much less than in 
ordinary menstruation. 

Cessation of Menstruation. — After a certain time changes occur 
showing that the woman is no longer fitted for reproduction; men- 
struation ceases, Graafian follicles are no longer matured, and the 
ovary becomes shrivelled and wrinkled on its surface. Analogous 
alterations take place in the uterus and its appendages. The Fallo- 
pian tubes atrophy, and are not unfrequently obliterated. The uterus 
decreases in size. The cervix undergoes a remarkable change which 
is readily detected on vaginal examination. The projection of the 
cervix into the vaginal canal disappears, and the orifice of the os 
uteri in old women is found to be flush with the roof of the vagina. 
In a large number of cases there is, after the cessation of menstrua- 
tion, an occlusion both of the external and internal os; the canal of 
the cervix, however, between them remains patulous, and is not un- 
frequently distended with a mucous secretion. 

Period of Cessation. — The age at which menstruation ceases varies 
much in different women. In certain cases it may cease at an unusu- 
ally early age, as between 30 and 40 years, or it may continue far 



OVULATION AND MENSTRUATION. 83 

beyond the average time, even up to 60 years; and exceptional, 
though perhaps hardly reliable instances, are recorded in which it 
has continued even to 80 or 90 years. These are, hoAvever, strange 
anomalies, which, like cases of unusually precocious menstruation, 
cannot be considered as having any bearing on the general rule. 
Most cases of so-called protracted menstruation will be found to be 
really morbid losses of blood depending on malignant or other forms 
of organic disease, the existence of which, under such circumstances, 
should always be suspected. 

In this country menstruation usually ceases between 40 and 50 
years of age. Raciborski says that the largest number of cases of 
cessation are met with in the 46th year. Is is generally said that 
women who commence to menstruate when very young, cease to do 
so at a comparatively early age, so that the average duration of the 
function is about the same in all women. Cazeaux and Raciborski, 
whose opinion is strengthened by the observations of Guy in 1500 
cases, 1 think, on the contrary, that the earlier menstruation com- 
mences, the longer it lasts, early menstruation indicating an excess 
of vital energy which continues during the whole childbearing life. 
Climate and other accidental causes, do not seem to have as much 
effect on the cessation as on the establishment of the function. It 
does not appear to cease earlier in warm than in temperate climates. 
The change of life is generally indicated by irregularities in the 
recurrence of the discharge. It seldom ceases suddenly, but it may 
be absent for one or more periods, and then occur irregularly; or it 
may become profuse or scanty, until eventually it entirely stops. 
The popular notions as to the extreme danger of the menopause are 
probably much exaggerated; although it is certain that at that time 
various nervous phenomena are apt to be developed. So far from 
having a prejudicial effect on the health, however, it is not an un- 
common observation to see an hysterical woman, who has been for 
years a martyr to uterine and other complaints, apparently take a 
new lease of life when her uterine functions have ceased to be in 
active operation, and statistical tables abundantly prove that the 
general mortality of the sex is not greater at this than at any other 
time. 

1 Med. Tinics and Gaz., 1 845. 



PART II 

PREGNANCY. 



CHAPTEE I. 



CONCEPTION AND GENEKATION. 

Generation in the human female, as in all mammals, requires 
the congress of the two sexes, in order that the semen, the male ele- 
ment of generation, may be brought into contact with the ovule, the 
female element of generation. 

Semen. — The semen secreted by the testicle of an adult male is a 
viscid, opalescent fluid, forming an emulsion when mixed with 
water, and having a peculiar faint odor, which is attributed to the 
secretions which are mixed with it, such as those from the prostate 
and Cowper's glands. On analysis it is found to be an albuminous 
fluid, holding in solution various salts, principally phosphates and 
chlorides, and an animal substance, spermatine, analogous to flbrine. 
Examined under a magnifying power of from 400 to 500 diameters, 
it consists of a transparent and homogeneous fluid, in which are float- 
ing a certain number of granules and epithelial cells, derived from 
the secretions mixed with it, and the characteristic sperm cells and 

spermatozoa which form its essen- 
tial constituents (Fig. 40). The 
sperm cells are large spherical 
vesicles, each containing from two 
to eight smaller cells, within which 
the spermatozoa are developed; 
and, as these soon escape and be- 
come free, the sperm cells are' 
only to be detected in the testicles 
themselves, while in semen that 
has been ejaculated they are rarely 
visible. The large parent cell, 
termed by Kobin the male ovule, 
forms within it several subsidiary 
cells by the segmentation of its 
granular contents. Within these 
secondarjr cells, or vesicles of evo- 
lution, which are believed by Kolliker to be developed from the 
nuclei of the parent cell, the spermatozoa are formed, and before 
ejaculation they may be seen coiled spirally in their interior. The 
external envelope then disappears, and a number of spermatozoa, one 




a,h. Sperm cells containing nuclei, each nucleus 
having within a spermatozoon, c. Nucleus, 
with nucleoli, d. Nucleus, with spermato- 
zoon, e. A cell, with a bundle of spermatic 
filaments. /, g, h. Spermatozoa. 



CONCEPTION AND GENERATION. 85 

being formed in each of the secondary cells, may be observed in the 
interior of the original parent cell. Eventually that also is absorbed, 
and the contained spermatozoa become liberated, and move about 
freely in the seminal fluid. As seen under the microscope, the sper- 
matozoa, which exist in healthy semen in enormous numbers, present 
the appearance of minute particles, not unlike a tadpole in shape. 
The head is oval and flattened, measuring about g^'ptli of an inch 
in breadth, and attached to it is a delicate filamentous expansion or 
tail, which tapers to a point so fine that its termination cannot be 

I seen by the highest powers of the microscope. The whole sperma- 
tozoon measures from ^-^th to e^tli °f an inch in length. The 
spermatozoa are observed to be in constant motion, sometimes very 
rapid, sometimes more gentle, which is supposed to be the means 
by which they pass upwards through the female genital organs. 
They retain their vitality and power of movement for a consider- 

I able time after emission, provided the semen is kept at a tempera- 
ture similar to that of the body. Under such circumstances thev 
have been observed in active motion from forty-eight to seventy-two 
hours after ejaculation, and they have also been seen alive in the tes- 
ticle as long as twenty-four hours after death. In all probability 

, they continue active much longer within the generative organs, as 
many physiologists have observed them in full vitality in bitches 
and rabbits, seven or eight days after copulation. Abundant leucor- 
rhoeal discbarges and acrid vaginal secretions destroy their move- 
ments, and may thus cause sterility in the female. On account of 
their mobility, the spermatozoa were long considered to be indepen- 
dent animalcules, a view which is by no means exploded, and has been 
maintained in modern times by' Pouchet, Joulin, and other writers, 
while Coste, Robin, Kdlliker, etc., liken their motion to that of cili- 
ated epithelium. There can be no doubt that the fertilizing power of 
the semen is due to the presence of the spermatozoa, although some 
of the older physiologists assigned it to the spermatic fluid. The 
former view, however, has been conclusively proved by the experi- 
ments of PreVost and Dumas, who found that on carefully removing 
the spermatozoa by filtration the semen lost its fecundating properties. 
Sites of Impregnation.— There has been great difference of opinion 
as to the part of the genital tract in which the spermatozoa and the 
ovule come into contact, and in which impregnation, therefore, occurs. 
Spermatozoa have been observed in all parts of the female genital 
organs in animals killed shortly after coitus, especially in the Fallo- 
pian tubes, and even on the surface of the ovary. The phenomena <>i' 
ovarian gestation, and the fact that fecundation has been proved to 
OCCUr in certain animals within the ovary, tend to BUppoii the idea 
that it may also occur in the human female before the rupture ofthe 

Graafian follicle. In order to do so, however, it is necessary for the 
spermatozoa to penetrate the proper structure of the follicle and the 
epithelial covering of the ovary, and no one has actually seen them 
doing so. Most probably the contacl of Hi-' spermatozoa and the 
ovule occurs very shortly after the rupture ofthe follicle, and in the 
outer part of the Fallopian tubes. Coste mentions that, unless the 
ovule is impregnated, it very rapidly degenerates after being ex] 



86 



PREGNANCY 



from the ovary, partly by inherent changes in the ovule itself, and 
partly because it then soon becomes invested by an albuminous 
covering which is impermeable to the spermatozoa. He believes, 
therefore, that impregnation can only occur either on the surface of 
the ovary, or just within the fimbriated extremity of the tube. 

Mode in which the ascent of the Semen is effected. — The semen is 
probably carried upwards chiefly by the inherent mobility of the 
spermatozoa. It is believed by some that this is assisted by other 
agencies; amongst them are mentioned the peristaltic action of the 
uterus and Fallopian tubes ; a sort of capillary attraction effected when 
the walls of the uterus are in close contact, similar to the movement 
of fluid in minute tubes ; and also the vibratile action of the cilia of 
the epithelium of the uterine mucous membrane. The action of the 
latter is extremely doubtful, for they are also supposed to effect the 
descent of the ovule, and they can hardly act in two opposite ways. 
The movement of the cilia being from, within outwards, it would cer- 
tainly oppose, rather than favor, the progress of the spermatozoa. 
It must, therefore, be admitted that they ascend chiefly through 
their own powers of motion. They certainly have this power to a 
remarkable extent, for there are numerous cases on record in which 
impregnation has occurred without penetration, and even when the 
hymen was quite entire, and in which the semen has simply been de- 
posited on the exterior of the vulva ; in such cases, which are far 
from uncommon, the spermatozoa must have found their way through 
the whole length of the vagina. It is probable, however, that under 
ordinary circumstances the passage of the spermatic fluid into the 
uterus is facilitated by changes which take place in the cervix during 
the sexual orgasm, in course of which the os uteri is said to dilate 
and close again in a rythmical manner. 1 

Mode of impregnation. — The precise method in which the sperma- 
tozoa effect impregnation was long a matter of doabt. It is now, 
however, certain that they actually penetrate the ovule, and reach its 

interior. This has been conclusively 
proved by the observations of Barry, 
Meissner, and others, who have seen the 
spermatozoa within the external mem- 
brane of the ovule in rabbits (Fig. -11). 
In some of the invertebrata a canal or 
opening exists in the zona pellucida, 
through which the spermatozoa pass. No 
such aperture has yet been demonstrated 
in the ovules of mammals, but its existence 
is far from improbable. According to the 
observations of Newport, several sperma- 
tozoa enter the ovule, and the greater the 
number that do so the more certain fecun- 
dation becomes. After the spermatozoa 
penetrate the zona pellucida they disinte- 
grate and mingle with the yelk, having, 



Fig. 41, 




Ovum of Eabbit containing sperma- 
tozoa. 
]. Zona pellucida. 2. The germs, 
consisting of two large cells, several 
smaller cells, and spermatozoa. 



How do the Spermatozoa enter the Uterus? by J. Beck, M.D. 



CONCEPTION AND GENERATION. 



87 



while doing so, imparted to the ovule a power of vitality, and ini- 
tiated its development into a new being. 

Progress of the Impregnated Ovule towards the Uterus. — The length 
of time which lapses before the fecundated ovule arrives in the cav- 
ity of the uterus has not yet been ascertained, and it probably varies 
under different circumstances. It is known that in the bitch it may 
remain eight or ten days in the Fallopian tube, in the guinea-pig 
three or four. In the human female the ovum has never been dis- 
covered in the cavity of the uterus before the tenth or twelfth day 
after impregnation. 

Changes immediately before and after Impregnation. — The changes 
which occur in the human ovule immediately before and after im- 
pregnation, and during its progress through the Fallopian tube, are 
only known to us by analogy, as, of course, it is impossible to study 
them by actual observation. We are in possession, however, of ac- 
curate information of what has been made out in the lower animals, 
and it is reasonable to suppose that similar changes occur in man. 
Immediately after the ovule has passed into the Fallopian tube, it is 
found to be surrounded by a layer of granular cells, a portion of the 
lining membrane of the Graafian follicle, which was described as the 
discus proligerus. As it proceeds along the tube these surrounding 
cells disappear, partly, it is supposed, by friction on the walls of the 
tube, and partly by being absorbed to nourish the ovule. Be this as 
it may, before long they are no longer observed, and the zona pellu- 
cida forms the outermost layer of the ovule. When the ovule has 
advanced some distance along the tube, it becomes invested with a 
covering of albuminous material, which is deposited around it in suc- 
cessive layers, the thickness of which varies in different animals. It 
is very abundant in birds, in whom it forms the familiar white of the 
egg. In some animals it has not been detected, so that its presence 
in the human ovule is uncertain. Where it exists it doubtless con- 
tributes to the nourishment of the ovule. Coincident with these 
changes is the disappearance of the germinal vesicle. At the same 
time the yelk contracts and becomes more solid; retiring, in one 
spot, from close contact with the zona 
pellucida, and thus forming a species of 
cavity called by Newport the respira- 
tory chamher, which in some animals is 
tilled with a transparent liquid. After 
this occurs the very peculiar phenome- 
non known as the cleavage of the yelk, 
which results in the formation or the 
membrane from which the foetus is de- 
veloped. It is preceded by the forma- 
tion at one point of the surface of the 
yelk of a minute transparenl globule of 
a bluish tint, sometimes of three or four 
separate globules which subsequently 
unite into one. This has received the 



Fig. 42. 




Po matlon of the " Polar Globule." 
Zona Pellucida. oonl 



Vetlele. 



Yelk. •". and f. Germinal 
.-,. The Polar Globule. 



OS PREGNANCY. 

name of the polar globule (Fig. 42), and seems to be formed from the 
hyaline substance of the yelk, from which it soon becomes entirely 
separated, and remains attached to the inner surface of the zona 
pellucida. It indicates the point at which the segmentation of the 
yelk begins, and where the cephalic extremity of the foetus will sub- 
sequently be placed. 

According to Eobin these changes occur in all ovules, whether 
they are impregnated or not, but if the ovule is not fecundated, no 
farther alterations occnr. Supposing impregnation has taken place, 
a bright clear vesicle, called the vitelline nucleus, very similar in 
appearance to a drop of oil, appears in the centre of the yelk. The 
segmentation of the yelk (Fig. 43) commences at the point where the 
polar globule is situated ; it begins to divide into two halves, and at 

Fig. 43. 




Segmentation of the Yelk. 

A. Ovum with first Embryo cell. B. Division of embryo cell and cleavage of the yelk around it. 

C, D, E. Further division of the yelk. 



the same time the vitelline nucleus becomes constricted in its centre, 
and separates into two portions, one of which forms a centre for each 
of the halves into which the yelk has divided. Each of these im- 
mediately divides into two, as does its contained portion of the vitel- 
line nucleus, and so on in rapid succession until the whole yelk is 
divided into a number of spheres, each of which consists of a clump 
of nucleated protoplasm. 

By these continuous dichotomous divisions the whole yelk is 
formed into a granular mass which, from its supposed resemblance 
to a mulberry, has been named the muriform body. When the sub- 
division of the yelk is completed, its separate spheres become con- 
verted into cells, consisting of a fine membrane with granular 
contents. These cells unite by their edges to form a continuous 
membrane (Fig. 44), which, through the expansion of the muriform 
body by fluid which forms in its interior, is distended until it forms 
a lining to the zona pellucida. This is the blastodermic membrane 
from which the foetus is developed. By this time the ovum has 



CONCEPTION AND GENERATION. 89 

reached the uterus, and, before proceeding to consider the further 
changes which it undergoes it will be well to study the alteration 
which the stimulus of impregnation has set on foot m the mucous 

Fig. 44. 



%K 




Formation of the Blastodermic Membrane from the cells of the Muriform Body. (After Joulin.) 
1. Layer of albuminous material surrounding. 2. The Zoua pellucida. 

membrane of the uterus, in order to prepare it for the reception and 
growth of its contents. 

Changes in the Uterine Mucous Membrane consequent on Preynancy. 
— Even before the ovum reaches the uterus, the mucous membrane 
becomes thickened and vascular, so that its opposing surfaces entirely 
fill the uterine cavity. These changes may be said to be the same 
in kind, although more marked and extensive in degree, as the alte- 
rations which take place in the mucous membrane in connection 
with each menstrual period. The result is the formation ofadistinct 
membrane, which affords the ovum a safe anchorage and protection, 
until its connections with the uterus arc more fully developed. A tier 
delivery, this membrane, which is by that time quite altered in 
appearance, is a1 leasl partially thrown off with tin 1 ovum; on which 
account it has received the name of the decidua, or caduca. 

Divisions of the Decidua. — The decidua consists of two principal 
portions, which, in early pregnancy, are separated from each other 

by a considerable interspace. Oi f these, called the decidua vera ) 

lines the entire uterine cavity, and is, no doubt, the original mucous 
lining of the uterus greatly hypertrophied. The second, the decidua 
rejlcxa, is closely applied round the ovum; and it is probably formed 
by the sprouting of the decidua vera around the ovum al the point 
on which the hitter rests, so thai it eventually completely surrounds 
it. As the ovum enlarges, the decidua reflexa is necessarily stretched, 
until it conies everywhere into contact with the decidua vera, with 
which it firmly unites. After the third month of pregnancy true 
7 



90 PREGNANCY. 

union has occurred, and the two layers of decidua are no longer 
separate. The decidua serotina, which is described as a third portion, 
is merely that part of the decidua vera on which the ovum rests, and 
where the placenta is eventually developed. 

Views of William and John Hunter. — It is needless to refer to the 
various views which have been held by anatomists as to the struc- 
ture and formation of the decidua. That taught by John Hunter 
was long believed to be correct, and down to a recent date it received 
the adherence of most physiologists. He believed the decidua to be 
an inflammatory exudation which, on account of the stimulus of 
pregnancy, was thrown out all over the cavity of the uterus, and 
soon formed a distinct lining membrane to it. "When the ovum 
reached the uterine orifice of the Fallopian tube it found its entrance 
barred by this new membrane, which accordingly it pushed before 
it. This separated portion formed a covering to the ovum, and 
became the decidua reflexa; while a fresh exudation took place at 
that portion of the uterine wall which was thus laid bare, and this 
became the decidua vera. William Hunter had much more correct 
views of the decidua, the accuracy of which were at the time much 
contested, but which have recently received full recognition. He 
describes the decidua in his earlier writings as an hypertrophy of 
the uterine mucous membrane itself, a view which is now held by 
all physiologists. 

Structure of the Decidua. — W r hen the decidua is first formed it is a 
hollow triangular sac lining the uterine cavity (Fig. 45), and having 
three openings into it, those of the Fallopian tubes at its upper 
angles, and one, corresponding to the internal os uteri, below. If, 
as is generally the case, it is thick and pulpy, these openings are 
closed up and can no longer be detected. In early pregnancy it is 
well developed, and continues to grow up to the third month of 
utero-gestation. After that time it commences to atrophy, its adhe- 
sion with the uterine walls lessens, it becomes thin and transparent, 
and is ready for expulsion when delivery is effected. When it is 
most developed, a careful examination of the decidua enables us to 
detect in it all the elements of the uterine mucous membrane greatly 
hypertrophied. Its substance chiefly consists of large round or oval 
nucleated cells and elongated fibres, mixed with the tubular uterine 
gland ducts, which are much elongated and filled with cylindrical 
epithelium cells, and a small quantity of milky fluid. According to 
Friedlander the decidua is divisible into two layers: the inner being 
formed by a proliferation of the corpuscles of the sub-epithelial con- 
nective tissue of the mucous membrane; the deeper, in contact with 
the uterine walls, out of flattened or compressed gland ducts. In an 
early abortion the extremities of these ducts may be observed by a 
lens on the external or uterine surface of the decidna, occupying the 
summit of minute projections, separated from each other by depres- 
sions. If these projections be bisected they will be found to contain 
little cavities, filled with lactescent fluid, which were first described 
by Montgomery of Dublin, and are known as Montgomery 1 s cups. 
They are in fact the dilated canals of the uterine tubular glands. 



CONCEPTION AND GENERATION. 



91 



On the internal surface of such an early decidua a number of shallow 
depressions may be made out, which are the open mouths of these 
ducts. 

Fig. 45. 




Aborted Ovum of about forty days, showing the Triangular Shape of the Decidua (which is hiid 
open), and the Aperture of the Fallopiau Tube. (After Coste.) 

Formation of the Decidua Reflexa. — When the ovum reaches the 
uterine cavity it soon becomes imbedded in the folds of the hyper- 
trophied mucous membrane, which almost entirely fills the uterine 



Fig. 46. 



Fig. 47. 



Fig. 48. 





Formation of Decidna. 
(The decidua is colored 

black, the < i v 1 1 1 1 1 is repre- 
ti mted as engaged between 

two projecting folds of 
membrane.) 



Projecting Polda of Membrane 
growing np around tbe ovum. 



(After Dalton.) 




-ii..\\ Ing «> > urn completely 
■arronnded by the Decidna 
Reflexa. 



cavity. Asm rule it is attached to some point near tbe opening of 
a Fallopian tube, tbe swollen folds of mucous membrane preventing 



92 PREGNANCY. 

its descent to the lower part of the uterus ; in exceptional circum- 
stances, however, as in women who have borne many children, and 
have a more than usually dilated uterine cavity, it may fix itself at 
a point much nearer the internal os uteri. According to the now 
generally accepted opinion of Coste, the mucous membrane at the 
base of the ovum soon begins to sprout around it and gradually ex- 
tends until it eventually completely covers the ovum (Figs. 46-48), 
and forms the cleciclua reflexa. Coste describes, under the name of 
the umbilicus, a small depression at the most prominent part of the 
ovum, which he considers to be the indication of the point where the 
closure of the decidua reflexa is effected. There are some objections 
to this theory, for no one has seen the decidua reflexa incomplete 
and in the process of formation, and, on examining its external surface, 
that is, the one furthest from the ovum, its microscopical appearance 
is identical with that of the inner surface of the decidua vera. To 
meet these difficulties, Weber and Groodsir, whose views have been 
adopted by Priestley, contended that the decidua reflexa is "the 
primary lamina of the mucous membrane, which, when the ovum 
enters the uterus, separates in two-thirds of its extent from the layers 
beneath it, to adhere to the ovum ; the remaining third remains 
attached, and forms a centre of nutrition." According to this view 
the decidua vera would be a subsequent growth over the separated 
portion, and the decidua serotina the portion of the primary lamina 
which remained attached. In this way the fact of the opposed sur- 
faces of the decidua vera and reflexa bein^ identical in structure 

Fig. 49. 




An Ovum removed from Uterus, and part of the Decidua Vera cut away. (After Coste.) 
". Decidua vera, showing the follicles opening on its iuncv surface, b. Inner extremity of Fallo- 
pian tube. c. Flap of decidua reflexa. d. Ovum. 

would be accounted for. The difficulty which this theory is intended 
to meet, does not seem so great as is supposed, for if, as is likely, it 
is only the epithelial or internal surface of the mucous membrane 



CONCEPTION AND GENERATION. 93 

which sprouts over the ovum, and not its deeper layers, the facts of 
the case would be sufficiently met by Coste's view. 

Up to the third month of 'pregnancy the decidua reflexa and era are 
not in close contact, and there may even be a considerable interspace 
between them, which sometimes contains a small quantity of mucous 
fluid, called the hydroperione. This fact may account for the curious 
circumstance, of which many instances are on record, that a uterine 
sound may be passed into a gravid uterus in the early months of 
pregnancy without necessarily producing abortion, and also for the 
occasional occurrence of menstruation after conception (Figs. 49 and 
75). Eventually, by the growth of the ovum, the decidua reflexa 
comes closely into contact with the vera, and the two become inti- 
mately blended and inseparable. 

Decidua at the end of Pregnancy and after Delivery. — As pregnancy 
advances the decidua alters in appearance and becomes fibrous and 
thin. In the later months of utero-gestation fatty degeneration of 
its structure commences, its vessels and glands are obliterated, and 
its adhesion to the uterine Avails is lessened, so as to prepare it for 
separation. As we shall subsequently see, this fatty degeneration 
was assumed by Simpson to be the determining cause of labor at 
term. 

Viev:s of Robin. — It was long believed that the entire decidua was 
thrown off after labor, leaving the muscular coat of the uterus bare 
and denuded, and that a new mucous membrane was formed during 
convalescence. According to Robin, 1 whose views are corroborated 
by Priestley, no such denudation of the muscular tissue of the uterus 
ever occurs, but a portion of the decidua always remains attached 
after delivery. After the fourth month of pregnancy they believe 
that a new mucous membrane is formed under the decidua, which 
remains in a somewhat imperfect condition till after delivery, when 
it rapidly develops and assumes the proper functions of the mucous 
lining of the uterus. Robin also believes that that portion of the 
decidua which covers the placental site, the so-called decidua serotina, 
is not thrown oil" with the membranes, like the decidua vera and 
reflexa, but remains attached to the uterine walls, a thin layer of it 
only being expelled with the placenta, on which it may he observed. 
Duncan 8 entirely dissents from these views, and docs nol admit the 
formation of a new mucous membrane during the later months of 
utero-gestation. He believes that the greater portion of the decidua 
is thrown o&\ l»ut that part remains, and from this the fresh mucous 
membrane is developed. This view is similar to that of Spiegelberg, 
who holds that the portion of the decidua thai is expelled is the more 
superficial of the two layers described by Friedlander, composed 
chiefly of the epithelial elements, while the deeper or glandular 
layer remains attached t<> the walls of the uterus. From the epithe- 
lium of the glands a new epithelial layer is rapidly developed after 
delivery. This theory hears on the well-known analogy of the uterus 

1 Mrnioircs (Ir L'Acad. Imp. (]c Mnl. 1861. 

2 Researches in Obstetrics, p. L86etseq. 



94 



PREGNANCY. 



after delivery to the stump of an amputated limb; an old simile, 
principally based on the erroneous theory that the whole muscular 
tissue of the uterus was laid bare. This, as we have seen, is not the 
case, but the simile so far holds good in that the mucous lining is 
deprived of its epithelial covering ; and this fact, together with the 
existence of numerous open veins on the interior of the uterus, readily 
explains the extreme susceptibility to septic absorption which forms 
so peculiar a characteristic of the puerperal state. 

Changes in the Ovum. — Before we commenced the study of the de- 
cidua we had traced the impregnated ovum into the uterine cavity, 
and described the formation of the blastodermic membrane by the 
junction of the cells of the muriform body. We must now proceed 
to consider the further changes which result in the development of 
the foetus, and of the membranes that surround it. It would be 
quite out of place in a work of this kind to enter into the subject of 
embryology at any length, and we must therefore be content with 
such details as are of importance from a practical point of view. 

Division of the Blastodermic Membrane into Layers. — The blasto- 
dermic membrane, which forms a complete spherical lining to the 
ovum, between the yelk and the zona pellucicla, soon divides into 
two layers, the most external, called the epiblast, and an internal, the 
hypoblast, and between them is subsequently developed a third known 
as the mesoblast. From these three layers are formed the entire 
foetus ; the epiblast giving origin to the bones, muscles, and integu- 
ments, the nervous system, the serous membranes, and the amnion ; 
the hypoblast forming the mucous membranes and the alimentary 
canal ; and the mesoblast the circulating system. 

The Area Germinativa. — Almost immediately after the separation of 
the blastodermic membrane into layers, one part of it becomes thick- 
ened by the aggregation of cells, and is called the area germinativa. 

Fig. 50. 




Diagram of area germinativa, showing the primitive trace and area pellucuia. 

This is at first round and then oval in shape, and in its centre the 
first trace of the foetus may be detected in the form of a narrow 
straight line, the primitive trace. Surrounding it are some cells more 
translucent than those of the rest of the area germinativa, and hence 



CONCEPTION AND GENERATION. 



95 



Fig. 51. 



".T 



called the area pellucida (Fig. 50). On each, side of the primitive 
trace two elevated ridges soon arise, the laminae dorscdes, which grad- 
ually unite posteriori}' to form a cavity within which the cerebro- 
spinal column is subsequently developed. Anteriorly they join to 
form the thoracic and abdominal cavities, inclosing portions of the 
epiblast, from which the serous membranes of the body are devel- 
oped. The minute embryo thus formed soon curves on itself, with 
its convexity outwards, and a distinct thickening is observed at one 
end, which is subsequently developed into the cephalic extremity of 
the foetus, while, at its other end, a thickening less marked in degree 
forms the caudal extremity. 

Formation of the Amnion. — At each of these points, very soon after 
the formation of the embryo, two hollow processes may be observed 
which gradually arch over the dorsal 
surface of the foetus, until they meet 
each other and form a complete en- 
velope to it. At the ventral surface 
these processes are separated by the 
whole length of the embryo, but they 
here also gradually approach each 
other, and eventually surround what 
is subsequently the umbilical cord, 
and blend with the integument of the 
foetus at the point of its insertion. In 
this way is formed the amnion (Fig. 
51), consisting of two layers ; the in- 
ternal, derived from the epiblast, is 
formed of tessellated epithelial cells, 
the external arising from the meso- 
blast, is formed of cells like those of 
young connective tissue. Before the 
folds of the amnion unite, the free edge 
of each is bent outwards and spreads 
around the ovum, immediately within the zona pellucida, forming a 
lining to it, termed by Turner the sub-zonal membrane, which is con- 
nected with the development of the chorion. The amnion is the most 
internal of the membranes surrounding the foetus, and will presently 
be studied more in detail. It soon becomes distended with fluid, the 
liquor amnii, and as this increases in amount it separates the amnion 
m<»re and more from the uterus^ 

Changes in the Mucous Layer. — During this time the innermost 
layer of the blastodermic membrane or hypoblast is also developing 
two projection- at either extremity of the foetus, and these gradually 
approach each other anteriorly. A.8 the hypoblast ia in contact with 
the yelk, when these meet they have the effect of dividing the yelk 
into two portions. One, and the Bmaller of the two. forms eventu- 
ally the intestinal canal of the foetus : the other, and much the larger, 
contains the greater portion of the yelk, and forms the ephemeral 
structure known as the umbilical vesicle, from which the foetus derives 
most of its nourishment during the early stage of it.- existence. Its. 




Development of the Amnion. 
Vitelline membrane. 2. External layer 
of blastodermic membrane. •'*. Internal 
layers forming the umbilical vesicle. 4. 
Umbilical vessels. .0. Projections Conn- 
ing amnion. 6. Allantoic 



96 



PREGNANCY. 



communication with the abdominal cavity of the foetus is through 
the constricted portion at the point of division called the vitelline 
duct (Fig. 52). An artery and vein, the omphalo-mesenteric, ramify 
on the vesicle and its duct. 



Fig. 52. 




I. Exo-chorion. 2. External layer ofblastodermic membrane. 
5. Amnion. 6. Embryon. 7. Allautois increasing in size. 



3. Umbilical vesicle. 4. Its vessels. 



Fig. 53, 



As the amnion increases in size, it pushes back the umbilical 
vesicle towards the external membrane of the ovum, between which 
and the amnion it lies (Fig. 53) ; and when the allantois is developed, 
it ceases to be of any use, and rapidly shrinks and dwindles away. 
In most mammals no trace of it can be found 
after the fourth month of utero-gestation ; in 
some, including the human female, it is said to 
exist as a minute vesicle at the placental end of 
the umbilical cord at the full period of preg- 
nancy. The umbilical vesicle is filled with a 
yellowish fluid, containing many oil and fat 
globules, similar to the yelk of an egg. 

The Allantois. — Somewhere about the twen- 
tieth day after conception a small vesicle is 
formed towards the caudal extremity of the 
foetus, which is called the allantois. It is well 
developed and persistent in many of the lower 
animals, but in man it is merely a temporary 
structure, and disappears after it has fulfilled its 
functions. Its study, therefore, in the human 
race has been a matter of difficulty, and it was 
long before we were possessed of any very re- 
liable information regarding it. There has been 
some difference of opinion as to its precise mode of origin. The 
most generally received opinion is that it begins as a diverticulum 
from the lower part of the intestinal canal. This, at first spherical, 
rapidly develops and becomes pyriform in shape, while, by a process 
of constriction, similar to that which occurs in the vitellus to form 




An Embryo of about twen- 
ty-five days laid open. 
(After Coste.) 
a. Chorion, b. Amnion. 
e. Cavity of chorion, d. 
Umbilical vesicle, e. Pedi- 
cle of allantois. /. Em- 
bryo. 



CONCEPTION AND GENERATION, 



97 



the umbilical vesicle, it becomes divided into two parts, communi- 
cating with each other, the smaller of them being eventually de- 
veloped into the urinary bladder. The larger portion, leaving the 
abdominal cavity along with the vitelline duct, rapidly grows until 
it comes into contact with the most external ovular membrane, the 
chorion, over the entire inner surface of which it spreads. In this 
part vessels soon develop : namely, the two umbilical arteries, de- 
rived from the abdominal aorta, and two umbilical veins, one of 
which subsequently disappears ; these, along with the vitelline duct 
and the pedicle of the allantois, form the umbilical cord. The main 
and very important function of the allantois, therefore, is to carry 
the foetal vessels up to the inner surface of the sub-zonal membrane. 



Fig. 54. 




I. Exo-chorion. 2. External layer of the blastodermic memlirane. 3. Allantois. 
4. Umbilical vesicle. 5. Amnion. 6. Embryou. 7. Pedicle of Allantois. 

Besides this purpose, the allantois, at a very early period, may receive 
the excretions of the foetus, and serve as an excrementitious organ. 
According to Cazeaux, scarcely a trace of the allantois can he seen 
a few da} r s after its formation. Its lower part or pedicle, bowever, 
long remains distinct, and forms part of the umbilical cord; and 
traces of it may be found even in adult life in the form of the urachus, 
which is really the dwindled pedicle, and forms one of the Ligaments 
of t lie bladder. 

The Corps Reticule or Viiriform Body. — Between the chorion and 
amnion is often found a gelatinous fluid, with minute filamentous 
processes traversing It, called by Velpeau the corps reticul^ which 
is not met with until the allantois comes into contad with the cho- 
rion, and which seems to he formed out of the tissue <>r that vesicle. 
It is analogous to the so-called Wharton's jelly found in the umbilical 
cord. When firsl formed it is highly vascular, bul the vee 
entirely disappear alter the placenta is formed, and the remainder of 
the chorionic villi atrophy. Sometimes it exists in considerable 
quantities, and should the chorion rupture at the end of pregnai 



98 PREGNANCY. 

it may escape and give rise to an erroneous impression that the 
liquor amnii has been discharged. 

Recapitulation. — Before proceeding to consider the foetal envelopes 
more at length, it may be useful to recapitulate the structures already 
alluded to as forming the ovum. In this we find : — 

1. The embryo itself. 

2. A fluid, the liquor amnii, in which it floats. 

3. The amnio?i, a purely foetal membrane surrounding the embryo, 
and containing the liquor amnii. 

4. The umbilical vesicle, containing the greater portion of the yelk, 
serving as a source of nutrition to the early embryo through the 
vitelline duct, and in which ramify the omphalo-mesenteric vessels. 

5. The allantois, a vesicle proceeding from the caudal extremity 
of the embryo, spreading itself over the interior of the ovum, and 
serving as a channel of vascular communication between the chorion 
and the foetus, through the umbilical vessels. 

6. An interspace between the outer layer of the ovum and the 
amnion, in which is contained the umbilical vesicle and allantois, and 
the corps reticule of Velpeau. 

7. The outer layer of the ovum, along with the sub-zonal mem- 
brane, forming the chorion and placenta. 

Amnion. — The amnion is the most internal of the two membranes 
surrounding the foetus ; its origin at an early period of foetal life has 
already been described. It is a perfectly smooth, transparent, but 
tough membrane, continuous with the integument of the foetus at the 
insertion of the umbilical cord, round which it forms a sheath. Soon 
after it is formed it becomes distended with a fluid, the liquor amnii, 
in which the foetus is suspended and floats. This fluid increases 
gradually in quantity, distending the amnion as it does so, until this 
is brought into contact with the inner surface of the chorion, from 
which it was at first separated by a considerable interspace. 

Structure. — The internal surface of the amnion is smooth and 
glistening, and on microscopic examination it is found to consist of 
a layer of flattened cells, each containing a large nucleus. These 
rest on a stratum of fibrous tissue which gives to the membrane its 
toughness, and by which it is attached to the inner surface of the 
chorion. It is entirely destitute of vessels, nerves, and lymphatics. 
The quantity of the liquor amnii varies much at different periods of 
pregnancy. In the early months it is relatively greater in amount 
than the foetus, which it outweighs. As pregnancy advances, the 
weight of the foetus becomes four or five times greater than that of 
the liquor amnii, although the actual quantity of fluid increases dur- 
ing the whole period of gestation. The amount of fluid varies much 
in different pregnancies. Sometimes there is comparatively little ; 
while at others the quantity is immense, reaching several pounds 
in weight, greatly distending the uterus, and thus, it may be, 
producing difficulty in labor. 

Its Quality. — At first the liquid is clear and limpid. As pregnancy 
advances it becomes more turbid and dense, from the admixture of 
epithelial debris derived from the cutaneous surface of the foetus. 



CONCEPTION AND GENERATION. 99 

In some cases, without actual disease, it may be dark green in color, 
and thick and tenacious in consistency. It has a peculiar heavy 
odor, and it consists chemically of water containing albumen, with 
various salts, principally phosphates and chlorides. 

Its Source. — The source of the liquor amnii has been much disputed. 
Some maintain that it is derived chiefly from the foetus, a view suffi- 
ciently disproved by the fact that the liquor amnii continues to in- 
crease in amount after the death of the foetus. Burdach believed 
that it is secreted by the internal surface of the uterus, and arrives 
in the cavity of the amnion by transudation through the membrane. 
Priestley — and this seems the most probable hypothesis — thinks that 
it is secreted by the epithelial cells lining the membrane, which 
become distended with fluid, burst, and pour their contents into the 
amniotic cavity. 

Functions and Uses. — The most obvious use of the liquor amnii is 
to afford a fluid medium in which the foetus floats, and so is protected 
from the shocks and jars to which it would otherwise be subjected, 
and from undue pressure from the uterine Avails. By distending the 
uterus it saves the uterus from injury, which the movements of the 
foetus might otherwise inflict, and the foetus is thus also enabled to 
change its position freely. The facility with which version by ex- 
ternal manipulation can be effected depends entirely on the mobility 
of the foetus in the fluid which surrounds it. Some have also su] >p< >se< 1 
that it prevents the foetus, in the early months of pregnancy, from 
forming adhesions to the amnion. In labor it is of great service, by 
lubricating the passages, but chiefly by forming, with the membranes 
a fluid wedge, which dilates the circle of the os uteri. 

chorion. — The chorion is the more external of the truly foetal mem- 
branes, although external to it is the decidua, having a strictly ma- 
ternal origin. It is a perfectly closed sac, its external surface, in 
contact with the decidua, being rough and shaggy from the develop- 
ment of villi (Fig. 50), its internal smooth and shining. As the 
ovum passes along the Fallopian tube it receives, as we have Been, 
an albuminous coating, and this, with the zona pellucida, is devel- 
oped into a temporary structure, the primitive chorion. On its exter- 
nal surface villous prominences soon appear, which have no ascer- 
tained structure, and which seem to supply the early ovum with 
nutriment by endosmotic absorption from tne mucous membrane of 
the uterus. This primitive chorion, however, has not been observed 
in the human subject, although it may be readily seen in the ova of 
some of the lower animals, such as the dog and the rabbit. Some 
twelve days after conception, when the blastodermic membrane is 
formed, tne true chorion appears. This is. iii fact formed by the 
epiblasi layer of the blastodermic membrane, which everywhere lines 
the zona pellucida or primitive chorion, and, by pressure, causes its 
absorption and disappearance. On the surface of the true chorion 

thus formed, which IS now the external envelope of the ovum, villi 
soon appear. 

Formation of the Villi,- These villi are hollow projections like the 
fingers of a glove, which are raised up from the surface ^i' the cho- 



100 PREGNANCY. 

rion (the hollows looking into the chorionic cavity), and they cover 
the whole external surface of the ovum, giving it the peculiar shaggy 
appearance observed in early abortions. They push themselves into 
the substance of the decidua, with which they soon become so firmly 
united that they cannot be separated without laceration. At first 
they are absolutely non-vascular, but soon the allantois, previously 
described, reaches the inner surface of the chorion, and spreads itself 
over the whole of it. Each villus now r receives a separate artery and 
vein, which gives off a branch to each of the sub-divisions into which 
the villus divides. These vessels are encased in a fine sheath of the 
allantois, which enters the villus along with them and forms a lining 
to it, described by some as the endochorion ; the external epithelial 
membrane of the villus, derived from the epiblast layer of the blasto- 
dermic membrane, being called the exo-chorion. The artery and 
vein lie side by side in the centre of the villus and anastomose at its 
extremity ; each villus thus having a separate circulation. 

Growth and Atrophy of the Villi. — As soon as the union of the 
allantois with the chorion has been effected, the villi grow very 
rapidly, give off branches, which, in their turn, give off secondary 
branches, and so form root-like processes of great complexity. In 
the early months of gestation they exist equally over the whole sur- 
face of the ovum. As pregnancy advances, however, those which are 
in contact with the decidua reflexa shrivel up and, by the end of the 
second month, disappear, being no longer required for the nutrition 
of the ovum. The chorion and decidua thus come into close contact, 
being united together by fibrons shreds, which, on microscopic ex- 
amination, are found to consist of the atrophied villi. A certain 
number of the villi, viz., those which are in contact with the decidua 
serotina, instead of dwindling away increase greatly in size, and 
eventually develop into the organ by wdiich the foetus is nourished 
— the placenta. 

Form of the Placenta. — This important organ serves the purpose 
of supplying nutriment to, and aerating the blood of, the foetus, and 
on its integrity the existence of the foetus depends. It is met with 
in all mammals, but is very different in form and arrangement in 
different classes. Thus, in the sow, mare, and in the cetacea, it is 
diffused over the whole interior of the uterus ; in the ruminants, it 
is divided into a number of separate small masses, scattered here and 
there over the uterine walls ; while in the carnivora and elephant, it 
forms a zone or belt round the uterine cavity. In the human race, 
as well as in rodentia, insectivora, etc., the placenta is in the form of 
a circular mass, attached generally to some part of the uterus near 
the orifices of the Fallopian tubes ; but it may be situated anywhere 
in the uterine cavity, even over the internal os uteri. As it is ex- 
pelled after delivery with the foetal membranes attached to it, and as 
the aperture in these corresponds to the os uteri, Ave can generally 
determine pretty accurately the situation in which the placenta was 
placed, by examining them after expulsion. The maternal surface 
of the placenta is somewhat convex, the foetal concave. Its size 
varies greatly in different cases, and it is usually largest when the 



CONCEPTION AXD GENERATION. 101 

child is big, but not necessarily so. Its average diameter is from 
six to eight inches, its weight from 18 to 21 oz., but, in exceptional 
cases, it has been found to weigh several pounds. Abnormalities of 
form are not very rare. Thus, the placenta has been found to be 
divided into distinct parts, a form said by Professor Turner to be 
normal in certain genera of monkeys ; or smaller supplementary 
placenta? (placentae succentarise), may exist round a central mass. 
These variations of shape are only of importance in consequence of 
a risk of part of the detached placeuta being left in utero after 
delivery, and giving rise to septicemia or secondary hemorrhage. 

Attachment of the Membranes. — The foetal membranes cover the 
whole foetal surface of the placenta, being reflected from its edges so 
as to line the uterine cavity, and being expelled with it after delivery. 
They also leave it at the insertion of the cord, to which they form a 
sheath. The cord is generally attached near the centre of the pla- 
centa, and from its insertion the umbilical vessels may be seen 
dividing and radiating over the whole foetal surface. 

Its Maternal Surface. — The maternal surface is rough and divided 
by numerous sulci, which are best seen if the placenta is rendered 
convex, so as to resemble its condition when attached to the uterus. 
A careful examination shows that a delicate membrane covers the 
entire maternal surface, unites the sulci together, and dips down be- 
tween them. This is, in fact, the cellular layer of the decidua serotma, 
which is separated and expelled witli the placenta, the deeper layer 
remaining attached in utero. Numerous small openings may be 
seen on the surface, which are the apertures of the veins torn off 
from the uterus, as also those of some arteries, which, after taking 
several sharp turns, open suddenly into the substance of the organ. 

Minute Structure of the Placenta. — As regards the minute structure 
of the placenta it is certain that it consists essentially of two dis- 
tinct portions, one foetal, consisting of the greatly hypertrophied 
chorionic villi, with their contained vessels, which carry the foetal 
blood so as to bring it into intimate relation with the maternal blood, 
and thus admit of the necessary < -115111203 occurring in it connected 
with the nutrition of the foetus; and the other maternal^ formed ou1 
of the decidua serotina and the maternal bloodvessels. These two 
portions are in the human female so intimately blended as to form 
the single deciduous organ which is thrown <>IV after delivery. These 
main facts are admitted by all, but considerable differences of opinion 
still exist among anatomists as to the precise arrangemenl of these 
parts. In the following sketch of the Bubjecl I shall describe the 
views most generally entertained, merely briefly indicating the points 
which are contested by various authorities. 

Fatal Portion of the Placenta,- The foetal portion of the placenta 
consists essentially of the ultimate ramifications of the chorion villi, 
which may be seen on microscopic examination in the Conn of club* 
shaped digitations which are given off at every | •« >- -i 1 >1« - angle from 
the stem of a parent trunk, just like the branches of a plant. With- 
in the transparent walls of the villi the capillary tubes of the con- 
tained vessels may he seen lying, distended with blood, and present- 



102 PREGNANCY. 

ing an appearance not unlike loops of small intestine. The capilla- 
ries are the terminal ramifications of the umbilical arteries and veins, 
which, after reaching the site of the placenta, divide and subdivide 
until they at last form an immense number of minute capillary 
vessels, with their convexities looking towards the maternal portion 
of the placenta, each terminal loop being contained in one of the 
digitations of the chorionic villi. Each arterial twig is accompanied 
by a corresponding venous branch, which unites with it to form the 
terminal arch or loop (Fig. 55). The foetal blood is carried through 
these arterial twigs to the villi, where it comes into intimate contact 




Placental Villus, greatly magnified. (After Joulin.) 
1. 2. Placental vessels, forming terminal loops. 3. Chorion tissue, forming external walls of villus. 
4. Tissue surrouudiug vessels. 

with the maternal blood, in consequences of the anatomical arrange- 
ments presently to be described ; but the two do not directly mix, as 
the older physiologists believed, for none of the maternal blood 
escapes when the umbilical cord is cut, nor can the minutest injections 
through the foetal vessels be made to pass into the maternal vascular 
system, or vice versa. In addition to the looped terminations of the 
umbilical vessels, Farre and Schroeder van der Kolk have described 
another set of capillary vessels in connection with each villus (Fig. 
56); This consists of a very fine network covering each villus, and 
very different in appearance from the convoluted vessels lying in its 
interior, which are the only ones which have been usually described. 
Dr. Farre believes that these vessels only exist in the early months of 



CONCEPTION AND GENERATION. 



103 



pregnancy, and that they disappear as pregnancy advances. Priestlev 1 
suggests that they may not be vessels at all, but lymphatics, which 



Fig. 56. 




a. Terminal villus of fcetal tuft, minutely injected. 6. Its nucleated nonvascular sheath. (After 
F arre.) 

may possibly absorb nutrient material from the mother's blood, and 
throw it into the foetal vascular system. The existence of lymphatics, 

Fig. 57. 




Diagram representing a Vertical Bectlonof the Placenta. (After Dalton | 
a,ri. Chorion, b, h. Decldoa. c,c,c,c. Orlflcet of nterlne slnntea. 

ot nerves, in the placenta, however, bas never been demonstrated, 
and they arc believed nol to exist. 

1 The Gravid Uterus, p. 52. 



104 



PREGNANCY. 



Maternal Portion of the Placenta. — As generally described, the 
maternal portion of the placenta consists of large cavities, or of a 
single large cavity, which contain the maternal blood, and into which 
the villi of the chorion penetrate (Fig. 57). Into this maternal part 
of the viscns the curling arteries of the uterus pour their blood, 
which is collected from it by the uterine sinuses. The villi of the 
chorion, therefore, are suspended in a sac filled with maternal blood, 
which penetrates freely between them, and with which they are 
brought into very intimate contact. Dr. John Eeid believed that 
only the delicate internal lining of the maternal vessels entered the 
substance of the placenta, to form the sac just spoken of. Into this 
the villi project, pushing before them the membrane forming the 
limiting wall of the placental sinuses, each of them in this way 
receiving an investment, just as the fingers of a hand are covered by 
a glove (Fig. 58). 



Fig. 58. 



Fig. 59. 



0~. ... 




Diagram illustrating the mode in which a pla- 
cental villus derives a covering from the vascu- 
lar system of the mother. (After Priestley.) 

a. Villus having three terminal digitations pro- 
jecting into b. Cavity of the mother's vessel, c. 
Dotted lines representing coat of vessel. 




The Extremity of a Placental Villus. 
(After Goodsir.) 

a. External membrane of villus (the lining 
membrane of vascular system of Weber). 

b. External cells of villus derived from 
decidua. 

c. c. Nuclei of ditto. 

d. The space between the maternal and 
foetal portions of villus. 

e. Its internal membrane. 
/. Its internal cells. 

g. The loop of umbilical vessels. 



Theory of Goodsir. — Schroeder van der Kolk and Goodsir (Fig. 59) 
were of opinion that not only were the maternal bloodvessels con- 
tinued into the substance of the placenta, *but also the processes of 
the decidua, which accompanied the vessels and were prolonged over 
each villus, so as to separate it from the limiting membrane of the 
maternal sinuses. Each villus would thus be covered by two layers 
of fine tissue, one from the internal lining membrane of the maternal 
bloodvessels, the other from the epithelial cells of the decidua. 

Theory of Turner. — Turner, whose valuable researches on the com- 
parative anatomy of the placenta have thrown much light on its 
structure, points out that the placentae of all animals are formed on 
the same fundamental type, 1 in which the foetal portion consists of a 
smooth, plane-surfaced vascular membrane, covered with pavement 



1 Introduction to Human Anatomy, part 2. 



CONCEPTION AND GENERATION. 105 

epithelium, which is brought into contact with the maternal portion, 
consisting of a smooth, plane-surfaced vascular membrane, covered 
with columnar epithelium. The foetal capillaries are separated from 
the maternal capillaries only by two opposed layers of epithelium. 
In various animals the placentas are more or less specialized from 
the generalized form, in some to a much greater extent than others. 
In the human placenta the maternal vessels have lost their normal 
cylindrical form, and are dilated into a system of freely inter-com- 
municating placental sinuses, which are, in fact, maternal capillaries 
enormously enlarged, with their walls so expanded and thinned out 
that thev cannot be recognized as a distinct laver limiting: the sinus. 
Each foetal chorionic villus projecting into these sinuses is covered 
with a layer of cells distinct from those of the epithelial layer of the 
villus, and readily stripped from it. These are maternal in their 
origin, and are derived from the decidua, which sends prolongations 
of its tissue into the placenta. These cells, he believes, form a secret- 
ing epithelium which separates from the maternal blood a secretion 
for the nourishment of the foetus, which is, in its turn, absorbed by 
the villi of the chorion. 

Theory of Ercolani. — A view not very dissimilar to this has been 
advanced by Professor Ercolani of Bologna, who maintains that the 
maternal portion of the placenta is a new formation, strictly glandu- 
lar, and not vascular, in its structure. It is formed, he thinks, by 
the submucous connective tissue of the decidua serotina, and it dips 
down into the placenta and forms a sheath to each of the chorion 
villi, which it separates from the maternal blood. This new glandu- 
lar structure he describes as secreting a fluid, termed the " uterine 
milk,' 1 which is absorbed by the villi of the chorion, just as the 
mother's milk is absorbed by the villi of the intestines, and it is with 
this fluid alone that the chorion villi are in direct contact. The sheath 
thus formed to each villus is doubtless analogous to the layer of cells 
which Goodsir described as encasing each villus, but is attributed to 
a new structure formed after conception. 

Theory of Braxton Hicks. — The existence of the maternal sinus 
system in the placenta, is altogether denied by anatomists of emi- 
Dence whose views arc worthy of careful consideration. Prominenl 
amongsl these is Braxton Hicks, 1 who has written an elaborate paper 
on the subject. He holds that there is no evidence to prove thai the 
maternal blood is poured out into a cavity in which the chorion villi 
float, and he believes thai the curling arteries, instead of entering 
the so-called maternal portion of the placenta, terminate in the deci- 
dua serotina. The hypertrophied chorion villi at the site of the 
placenta are firmly attached to the decidual surface, into which their 
tips are embedded. The line of junction between the decidua reflexa 
and serotina forms a circumferential margin to, and limits the pla- 
centa. The arrangement of the futal portion of the placenta on this 
view is very similar to thai generally described, bu1 the villi are qo1 
surrounded by maternal blood at all, and nothing exists between 



( >bst. Trans., vol. xiv 



\06 PREGNANCY. 

them, unless it be a small quantity of serous fluid. The change in 
the foetal blood is effected by endosmosis, and Hicks suggests that 
follicles of the decidua may secrete a fluid, which is poured into the 
intervillous spaces for absorption by the villi. 

Functions of the Placenta. — It will thus be seen that anatomists of 
repute are still undecided as to important points in the minute ana- 
tomy of the placenta, which further investigation will doubtless 
clear up. The main functions of the organ are, however, sufficiently 
clear. During the entire period of its existence it fills the important 
office of both stomach and lungs to the foetus. Whatever view of 
the arrangement of the maternal bloodvessels be taken, it is certain 
that the foetal blood is propelled by the pulsations of the foetal heart 
into the numberless villi of the chorion, where it is brought into 
very intimate relation with the mother's blood, gives off its carbonic 
acid, absorbs oxygen, and passes back to the foetus, through the um- 
bilical veins, in a fit state for circulation. The mode of respiration, 
therefore, in the foetus is analogous to that in fishes, the chorion villi 
representing the gills, the maternal blood the water in which they 
float. Nutrition is also effected in the organ, and, by absorption 
through the chorion villi, the pabulum for the nourishment of the 
foetus is taken up. It also probably serves as an emunctory for the 
products of excretion in the foetus. Picard found that the blood in 
the placenta contained an appreciably larger quantity of urea than 
that in other parts of the body, this urea probably being derived 
from the foetus. Claude Bernard also attributed to it a glycogenic 
function, 1 supposing it to take the place of the foetal liver until that 
prgan was sufficiently developed. 

Degenerative Changes previous to Expulsion. — Finally, we find that 
the temporary character of the placenta is indicated by certain degen- 
erative changes, which take place in it previous to expulsion. These 
consist chiefly in the deposit of calcareous patches on its uterine sur- 
face, and in fatty degeneration of the villi, and of the decidual layer 
between the placenta and the uterus. If this degeneration be carried 
to excess, as is not unfrequently the case, the foetus may perish from 
a want of a sufficient number of healthy villi through which its 
respiration and nutrition may be effected. 

Umbilical Cord. — The umbilical cord is the channel of communi- 
cation between the foetus and placenta, being attached to the former 
at the umbilicus, to the latter generally near its centre, but some- 
times, as in the battledore placenta, at its edge. It varies much in 
length, measuring on an average from 18 to 24 inches, but in excep- 
tional cases being found as long as 50 or 60, and as short as 5 or 6 
inches. 

When fully formed it consists of an external membranous layer 
formed of the amnion, two umbilical arteries, one umbilical vein, and 
a considerable quantity of transparent gelatinous substance surround- 
ing the vessels, called Wharton's jelly, which is contained in a fine 
network of fibres, and is formed out of the tissue of the allantois. 

1 Acad, des Sciences, April, 1859. 



ANATOMY AND PHYSIOLOGY OF THE F(ETUS. 107 

At an early period of pregnancy, in addition to these structures, the 
cord contains the pedicle of the umbilical vesicle, with the omphalo- 
mesenteric vessels ramifying on it, and two umbilical veins, one of 
which soon atrophies and disappears. Iso nerves or lymphatics have 
been satisfactorily demonstrated in the cord, although such have 
been described as existing. The vessels of the cord are at first 
straight in their course, but shortly they become greatly twisted, the 
arteries being external to the vein, and in nine cases out of ten the 
twist is from left to right. Various explanations have been given of 
this peculiarity, none of them entirely satisfactory. Tyler Smith 
attributed it to the movements of the foetus twisting the cord, its 
attachment to the placenta being a fixed point ; this would not, how- 
ever, account for the frequency with which the spiral turns occur in 
one direction. Mr. John Simpson attributed it to the greater pres- 
sure of the blood through the right hypogastric artery, on account 
of that vessel having a more direct relation to the aorta than the 
left. The umbilical arteries give off no branches, and the vein con- 
tains no valves, nor can any vasa vasorum be detected in their coats 
after they have left the umbilicus. The umbilical arteries increase 
in size after they leave the cord, to divide on the surface of the pla- 
centa. This is the only example in the body in which arteries are 
larger near their terminations than their origin, and the object of 
this arrangement is probably to effect a retardation of the current of 
the blood distributed to the placenta. The tortuous course of the 
vein probably compensates for the absence of valves, and moderates 
the flow of blood through it. Distinct knots are not unfrequently 
observed in the cord, but they rarely have the effect of obstructing 
the circulation through it. They no doubt form when the foetus is 
very small. They may sometimes also be produced in labor by the 
child being propelled through a coil of the cord lying circularly round 
the os uteri. The so-called false knots are merely accidental nodosi- 
ties due to local enlargements of the vessels. 



CHAPTER 11. 

THE ANATOMY AND PHYSIOLOGY OF THE PCBTUS. 

It is obviously impossible to attempl anything like ;i full acoounl 
of the development of the various fceta] structures, or of tbeir growth 
during intra-uterine life. To do so would lead as far beyond the 
scope of this work, and would involve, a study of complex details 
only suitable in a treatise on Bi n bryology. It is of importance, how- 
ever, that the practitioner should nave it in his power to deter] e 

approximatively the age of the foetus in abortions or premature 



108 PKEGNANCY. 

labor, and for this purpose it is necessary to describe -briefly the ap- 
pearance of the foetus at various stages of its growth. 

1st Month. — The foetus in the first month of gestation is a minute 
gelatinous, and semi-transparent mass, of a grayish, color, in which 
no definite structure can be made out, and in which no head nor ex- 
tremities can be seen. It is rarely to be detected in abortions, being 
lost in surrounding blood clots. In the few examples which have 
been carefully examined it did not measure more than a line in length. 
It is however, already surrounded by the amnion, and the pedicle 
of the umbilical vesicle can be traced into the unclosed abdominal 
cavity. 

2d Month. — The embryo becomes more distinctly apparent, and is 
curved on itself, weighing about 62 grains, and measuring 6 or 8 
lines in length. The head and extremities are distinctly visible — 
the latter in the form of rudimentary projections from the body. 
The eyes are to be seen as small black spots on the side of the head. 
The spinal column is divided into separate vertebrae. The indepen- 
dent circulatory system of the foetus is now beginning to form, the 
heart consisting of only one ventricle and one auricle, from the 
former of which both the aorta and pulmonary arteries arise. On 
either side of the vertebral column, reaching from the heart to the 
pelvis, are two large glandular structures, the corpora Wolffiania, 
which consist of a series of convoluted tubes opening into an excre- 
tory duct, running along their external borders, and connected below 
with the common doaca of the genito-urinary and digestive tracts. 
They seem to act as secreting glands, and fulfil the functions of the 
kidneys before these are formed. Towards the end of the second 
month they atrophy and disappear, and the only trace of them in 
the foetus at term is to be found in the parovarium lying between 
the folds of the broad ligaments. At this stage of development 
there are met with in the human embryo, as in that of all mammals, 
four transverse fissures opening into the pharynx, which are analo- 
gous to the permanent branchiae of fishes. Their vascular supply is 
also similar, as the aorta at this time gives off four branches on each 
side, each of which forms a branchial arch, and these afterwards 
unite to form the descending aorta. By the end of the sixth week 
these, as well as the transverse fissures to which they are distributed, 
disappear. By the end of the second month the kidneys and supra- 
renal capsules are forming, and the single ventricle is divided into 
two by the growth of the inter- ventricular septum. The umbilical 
cord is quite straight, and is inserted into the lower part of the ab- 
domen. Centres of ossification are showing themselves in the infe- 
rior maxillary bones and the clavicle. 

3d Month. — The embryo weighs from 70 to 300 grains, and meas- 
ures from 2J to 3J inches in length. The forearm is well formed 
and the first traces of the fingers can be made out. The head is 
large in proportion to the rest of the body, and the eyes are promi- 
nent. The umbilical vesicle and allantois have disappeared, the 
greater portion of the chorion villi have atrophied, and the placenta 
is distinctly formed. 



ANATOMY AND PHYSIOLOGY OF THE FCETUS. 109 

Ath Month. — The weight is from 4 to 6 oz., and the length about 6 
inches. The convolutions of the brain are beginning to develop. 
The sex of the child can now be ascertained on inspection. The 
muscles are sufficiently formed to produce distinct movements of the 
limbs. Ossification is extending, and can be traced in the occipital 
and frontal bones, and in the mastoid processes. The sexual organs 
are differentiated. 

5th Month. — Weight about 10 oz. Length, 9 or 10 inches. Hair 
is observed covering the head, which forms about one-third of the 
length of the whole foetus. The nails are beginning to form, and 
ossification has commenced in the ischium. 

6th Month. — Weight about 1 lb. Length, 11 to 12| inches. The 
hair is darker. The eyelids are closed, and the membrana pupillaris 
exists ; eyelashes have now been formed. Some fat is deposited 
under the skin. The testicles are still in the abdominal cavity. The 
clitoris is prominent. The pubic bones have begun to ossify. 

7th Month. — Weight, from 3 to 4 lbs. Length, 13 to 15 inches. 
The skin is covered with unctuous, sebaceous matter, and there is a 
more considerable deposit of sub-cutaneous fat. The eyelids are 
open. The testicles have descended into the scrotum. 

8th Month. — -Weight, from 4 to 5 lbs. Length, 16 to 18 inches; 
and the foetus seems now to grow in thickness rather than in length. 
The nails are completely developed. The membrana pupillaris has 
disappeared. 

Foetus at Term. — At the completion of pregnancy the foetus weighs 
on an average 6J lbs., and measures about 20 inches in length. These 
averages are, however, liable to great variation. Remarkable his- 
tories are given by many writers of foetuses of extraordinary weight, 
which have been probably greatly exaggerated. Out of 3000 children 
delivered under the care of Cazeaux at various charities, one only 
weighed 10 lbs. There are, however, several carefully recorded 
instances of weight far exceeding this; but they are undoubtedly 
much more uncommon than is generally supposed. Dr. Ramsbotham 
mentions a foetus weighing 16 J lbs., and Cazeaux tells of one which 
he delivered by turning which weighed lb' Lbs., and measured 2 feet 
1J inches. Such overgrown children are almost invariably stillborn. 
On the other hand, mature children have been born and survived 
which have not weighed more than 5 lbs. [2| lbs. — Ed.] 

The average size of male children at birth, as in alter life, is some- 
what greater than that of female. Thus Simpson 1 found that oul of 
100 cases the male children averaged L0 oz. more in weight than the 
female, and J an inch more in length. A new-born child at term is 
generally covered to a greater or fess extenl with a greasy, unotuous 
material, the vernix caseosa, which is formed of epithelial scales and 
the secretion of the sebaceous glands, ami which is said to he of use 
in labor, by lubricating the surface of the child. The head is gene- 
rally covered with long* lark hair, which frequently falls off or changes 
in color shortly after birth. Dr. Wiltshire 1 has called attention to 

1 Selected Obst. Works, p. 827. ■ Lancet, February 11, L871. 



110 PREGNANCY. 

an old observation, that the eyes of all new-born children are of a 
peculiar dark steel-gray color, and that they do not acquire their 
permanent tint until some time after birth. The umbilical cord is 
generally inserted below the centre of the body. 

Anatomy of the Foetal Head. — The most important part of the 
foetus from an obstetrical point of view is the head, which requires a 
separate study, as it is the usual presenting part, and the facility of 
the labor depends on its accurate adaptation to the maternal passages. 

The chief anatomical peculiarity of interest, in the head of the 
foetus at term, is that the bones of the skull, especially of its vertex — 
which, in the vast majority of cases, has to pass first through the 
pelvis — are not firmly ossified as in adult life, but are joined loosely 
together by membrane or cartilage. The result of this is, that the 
skull is capable of being moulded and altered in form to a very con- 
siderable extent by the pressure to which it is subjected, and thus its 
passage through the pelvis is very greatly facilitated. This, however, 
is chiefly the case with the cranium proper, the bones of the face and 
of the base of the skull being more firmly united. By this means 
the delicate structures at the base of the brain are protected from 
pressure, while the change of form which the skull undergoes during 
labor implicates a portion of the skull where pressure on the cranial 
contents is least likely to be injurious. 

The divisions between the bones of the cranium are further of 
obstetric importance in enabling us to detect the precise position of 
the head during labor, and an accurate knowledge of them is there- 
fore essential to the obstetrician. 

The Sutures and Fontanelles. — We talk of them as sutures and 
fontanelles, the former being the lines of junction between the sepa- 
rate bones which overlap each other to a greater or less extent during 
labor ; the latter .membranous interspaces where the sutures join each 
other. 

The principal sutures are : 1st, the sagittal, which separates the 
two parietal bones, and extends longitudinally backwards along the 
vertex of the head. 2d. The frontal, which is a continuation of the 
sagittal, and divides the two halves of the frontal bone, at this time 
separate from each other. 3d. The coronal, which separates the 
frontal from the parietal bones, and extends from the squamous por- 
tion of the temporal bone across the head to a corresponding point 
on the opposite side ; and 4th, the lambdoidal, which receives its 
name from its resemblance to the Greek letter a, and separates the 
occipital from the parietal bones on either side. The fontanelles 
(Fig. 60) are the membranous interspaces where the sutures join — ■ 
the anterior and larger being lozenge-shaped, and formed by the junc- 
tion of the frontal, sagittal, and two halves of the coronal sutures. 
It will be well to note that there are, therefore, four lines of sutures 
running into it, and four angles, of which the anterior, formed by 
the frontal suture, is most elongated and well marked. The posterior 
fontanelle (Fig. 61) is formed by the junction of the sagittal suture 
with the two legs of the lambdoidal. It is, therefore, triangular in 
shape, with three lines of suture entering it in three angles, and is 



ANATOMY AXD PHYSIOLOGY OF THE FOETUS 



111 



much smaller than the anterior fontanelle, forming merely a depres- 
sion into which the tip of the finger can be placed, while the latter is 
a hollow as big as a shilling, or even larger. As it is the posterior 
fontanelle which is generally lowest, and the one most commonly felt 



Fig. 60. 



Fig. Gl. 





Anterior and I 



Fontanelles. 



Bi-parietal Diameter, Sagittal and Lambdoidal 
Sutures, with Posterior Fontanelles. 



during labor, it is important for the student to familiarize himself 
with it, and he should lose no opportunity of studying the sensations 
imparted to the finger by the sutures and fontanelles in the head of 
the child after birth. 

The Diameters of the Foetal Skull. — For the purpose of understand- 
ing the mechanism of labor, we must study the measurements of the 
foetal head in relation to the cavi- 
ty through which it has to pass. Fig. 62. 
They are taken from correspond- 
ing points opposite to each other, 
and are known as the diameters 
of the skull (Fig. 62). Those of 
most importance are : 1st. The 
occi i n to-mental, from the occipital 
protuberance to the point of the 
chin, 5.25" to 5.50". 2d. The oc- 
cipito-frontal, from the occiput to 
the centre of the forehead, 4.50" 
to 5". 3d. The sub-occipito-breg- 
matiCy from a point midway be- 
tween the occipital protuberance 
and the margin of the foramen 
magnum to the centre <>i' tin- an- 
terior fontanelle, :\:l'>" '. 4th. The 

cervico-bregmatic, from the anterior margin of the foramen magnum 
to the centre of the anterior fontanelle, 3.75". 5th. Tr 
bi-parietal, between the parietal protuberances, 3.75" i<> 1". 6th. Bi 
temporal, between the ears, 3.50 . 7th. Fronto-mental, from the apex 
of the forehead to the chin, 3.25". 




i ft -j. 

9 ft 1. 

7& 8. 



to-frontal diameter. 
< 'cclplto mental. 

i-bregmatie. 
Pronto-mental. 



112 PREGNANCY. 

Alteration of Diameter during Labor. — The length of these respec- 
tive diameters, as given by different writers, differs considerably — 
a fact to be explained by the measurements having been taken at 
different times ; by some just after birth, when the head was altered 
in shape by the moulding it had undergone ; by others when this 
had either been slight, or after the head had recovered its normal 
shape. The above measurements may be taken as the average of 
those of the normally-shaped head, and it is to be noted that the first 
two are most apt to be modified during labor. The amount of com- 
pression and moulding to which the head may be subjected, without 
proving fatal to the foetus, is not certainly known, but it is doubtless 
very considerable. Some interesting examples of the extent to which 
the head may be altered in shape in difficult labors have been given 
by Barnes, 1 who has shown, by tracings of the shape of the head 
taken immediately after delivery, that in protracted labor the oc- 
cipito-mental and occipitofrontal diameters may be increased more 
than an inch in length, while lateral compression may diminish the 
bi-parietal diameter to the same length as the inter-auricular. The 
foetal head is movable on the vertical column to the extent of a 
quarter of a circle; and it seems probable that the laxity of the liga- 
ments admits with impunity a greater circular movement than would 
be possible in the adult. 

Influence of Sex and Race on the Foetal Head. — On taking the ave- 
rage of a large number of measurements, it is found that the heads 
of male children are larger and more firmly ossified than those of 
females, the former averaging about half an inch more in circum- 
ference. Sir James Simpson attributed great importance to this fact, 
and believed that it was sufficient to account for the larger proportion 
of still births in male than in female children, as well as for the greater 
difficulty of labor and the increased maternal mortality that are found 
to attend on male births. His well-known paper on this subject, 
which has given rise to much controversy, is full of the most elaborate 
details, and so great did he believe the foetal influence to be, that he 
calculated that between the years 1834 and 1837 there were lost in 
Great Britain, as a consequence of the slightly larger size of the male 
than of the female head at birth, about 50,000 lives, including those 
of about 46,000 or 47,000 infants, and of between 3000 and 4000 
mothers who died in childbed. 2 It is probable that race and other 
conditions, such as civilization and intellectual culture, have con- 
siderable influence on the size of the foetal skull, but we are not in 
possession of sufficiently accurate data to justify any very positive 
opinion on these points. 

Position of the Foetus in Titer o. — In the very large majority of cases 
the foetus lies in utero with the head downwards, and is so placed as 
to be adapted in the most convenient way to the cavity in which it 
is placed. The uterine cavity is most roomy at the fundus, and 
narrowest at the cervix, and the greatest bulk of the foetus is at the 
breech, so that the largest part of the child usually lies in the part 

1 Obst. Trans., vol. vii. 2 Selected Obstet. Works, p. 363. 



ANATOMY AND PHYSIOLOGY OF THE F(ETUS. 113 

of the uterus best adapted to contain it. The various parts of the 
child's body are further so placed, in regard to each other, as to take 
up the least possible amount of space. (See frontispiece.) The body 
is bent so that the spine is curved with its convexity outwards, this 
curvature existing from the earliest period of development; the chin 
is flexed on the sternum; the forearms are flexed on the arms, and 
lie close together on the front of the chest; the legs are flexed on 
the thighs, and the thighs -drawn up on the abdomen; the feet are 
drawn up towards the leg; the umbilical cord is generally placed 
out of reach of injurious pressure, in the space between the arms 
and the thighs. Variations from this attitude, however, are not 
uncommon, and are not, as a rule, of much consequence. Although 
the cranial presentations are much the most common, averaging 96 
out of every 100 cases, other presentations are by no means rare, the 
next most frequent being either that of the breech, in which the long 
diameter of the child lies in the long diameter of the uterine cavity, 
or some variety of transverse presentation, in which the long dia- 
meter of the foetus lies obliquely across the uterus, and no longer 
corresponds to its longitudinal axis. 

Changes of Foetal Position during Pregnancy. — It was long believed 
that the head presentation was only assumed towards the end of 
pregnancy, when it was supposed to be produced by a sudden move- 
ment on the part of the foetus, knoAvn as the culbute. It is now well 
known that, in the large majority of cases, the head is lowest during 
all the latter part of pregnancy, although changes in position are 
more common than is generally believed to be the case, and presen- 
tation of parts other than the head is much more frequent in pre- 
mature labor than in delivery at term. In evidence of the last 
statement, Churchill says that in labor at the seventh month the 
head presents only 83 times out of 100 when the child is living, and 
that as many as 53 per cent, of the presentations are preternatural 
when the child is still-born. The frequency with which the foetus 
changes its position before delivery has been made tin 1 subject of 
investigation by various German obstetricians, and the fad ran be 
readily ascertained by examination. Valenta 1 found that out of 
nearly 1000 cases, carefully and frequently examined by him, in 67.6 
per cent, the presentation underwent no change in tin- latter months 
of pregnancy, but in the remaining 42.4 per cent, a change could be 
readily detected. These alterations were, found to be mos1 frequent 
in multiparas, and the tendency was for abnormal presentations to 
alter into normal ones. Thus it was common for transverse presenta- 
tions to alter longitudinally, and bin rare for breech presentations to 
change into head. The ease with which these changes are effected 
no doubt depends, in a considerable degree, <>n the laxity of the 
uterine parietes, and <>n the ^renter quantity of amniotic fluid, by 
both of which the free mobility of the foetus is favored. 

Detection of Feel \a I Position by Abdominal Palpation.- -The facility 
with which the position of the foetus in iitero can be ascertained by 

1 .M«»n. f. Geburt., 1866. 



114 



PREGNANCY 



abdominal palpation has not been generally appreciated in obstetric 
works, and yet, by a little practice, it is easy to make it out. Much, 
information of importance can be gained in this way, and it is quite 
possible, under favorable circumstances, to alter abnormal presen- 
tations before labor has begun. For the purpose of making this 
examination, the patient should lie at the edge of the bed, with her 
shoulders slightly raised, and the abdomen uncovered. The first 
observation to make is to see if the longitudinal axis of the uterine 
tumor corresponds with that of the mother's abdomen ; if it does, the 
presentation must be either a head or a breech. By spreading the 
hands over the uterus (Fig. 63), a greater sense of resistance can be 

Fig. 63. 




Mode of ascertaining the Position of the Foetus by Palpation. 

felt, in most cases, on one side than on the other, corresponding to 
the back of the child. By striking the tips of the fingers suddenly 
inwards at the fundus, the hard breech can generally be made out, 
or the head, still more easily, if the breech be downwards. When 
the uterine walls are unusually lax, it is often possible to feel the 
limbs of the child. These observations can be generally corroborated 
by auscultation, for in head presentations the foetal heart can usually 
be heard below the umbilicus, and in breech cases above it. Trans- 
verse presentations can even more easily be made out by abdominal 
palpation. Here the long axis of the uterine tumor does not corre- 
spond with the long axis of the mother's abdomen, but lies obliquely 
across it. By palpation the rounded mass of the head can be easily 
felt in one of the mother's flanks, and the breech in the other, while 
the foetal heart is heard pulsating nearer to the side at which the 
head is detected. 

Explanation of the Position of the Foetus in Titer o. — The reason why 
the head presents so frequently has been made the subject of much 
discussion. The oldest theory was, that the head lay over the- os 



ANATOMY AND PHYSIOLOGY OF THE FCETUS. 



115 



uteri as the result of gravitation, and the influence of gravity, although 
contested by many obstetricians, prominent among whom were Du- 
bois and Simpson, has been insisted upon as the chief cause by others. 
Dr. Duncan being one of the most strenuous advocates of this view. 
The objections urged against the gravitation theory were drawn 
partly from the result of experiments, and partly from the frequency 
with which abnormal presentations occurred in premature labors, 
when the action of gravity could not be supposed to be suspended. 
The experiments made by Dubois went to show that when a foetus 
was suspended in water gravitation caused the shoulders, and not 
the head, to fall lowest. He, therefore, advanced the hypothesis that 
the position of the foetus was due to instinctive movements, which it 
made to adapt itself to the most comfortable position in which it 
could lie. It need only be remarked that there is not the slightest 
evidence of the foetus possessing any such power. Simpson proposed a 
theory which was much more plausible. He assumed that the foetal 
position was due to reflex movements produced by pl^sical irrita- 
tions to which the cutaneous surface of the foetus is subjected from 
changes of the mother's position, uterine contractions, and the like. 
The absence of these movements, in the case of the death of the foetus, 
would readily explain the frequency of mal-presentation under such 
circumstances. The obvious objection to this theory, complete as it 
seems to be, is the absence of any proof that such constant extensive 
reflex movements really do occur in utero. Dr. Duncan has very 
conclusively disposed of the principal objections which have been 




,a 



Diagram Illustrating the Effect of Gravity on the Fcetus. (After Duncan.) 

a, h, is parallel to the axis of the pregnant uterus and peh i<- brim. 0, -/. -. i- 1 perpendloular line. 

e, the centre of gravity of the foetus, d, the centre of flotation. 



raised against the influence of gravitation, and when an obi 
planation of so simple a kind exists it seems useless fco seek further 
for another. He has shown thai Dubois' experiments did ool accu- 
rately represent the state of the foetus in utero, and that, during the 



116 PREGNANCY. 

greater part of the day, when the woman is upright, or lying on her 
back, the foetus lies obliquely to the horizon at an angle of about 30°. 
The child thus lies, in the former case, on an inclined plane, formed 
by the anterior uterine wall and by the abdominal parietes, in the 
latter by the posterior uterine wall and the vertebral column. Down 
the inclined plane so formed the force of gravity causes the foetus 
to slide, and it is only when the woman lies on her side that the 
foetus is placed horizontally, and is not subjected in the same degree 
to the action of gravity (Fig. 64). The frequency of mal-presenta- 
tions in premature labors is explained by Dr. Duncan partly by the 
fact that the death of the child (which so frequently precedes such 
cases) alters its centre of gravity, and partly by the greater mobil- 
ity of the child and the greater relative amount of liquor amnii 
(Fig. 65). The influence of gravitation is probably greatly assisted 

N Fig. 65. 



Illustrating the greater Mobility of the Foetus and the Larger relative. Amount of Liquor Amnii in 
Early Pregnancy. (After Duncan.) 
a, b. Axis of pregnant uterus. b, h. A horizontal line. 

by the contractions of the uterus which are going on during the 
greater part of pregnancy. The influence of these was pointed out 
by Dr. Tyler Smith, who distinctly showed that the contractions of 
the uterus preceding delivery exerted a moulding or adapting influ- 
ence on the foetus, and prevented undue alterations of its position. 
Dr. Hicks proved 1 that these uterine contractions are of constant 
occurrence from the earliest period of pregnancy, and there can be 
little doubt that they must have an important influence on the body 
contained within the uterus. 

Functions of the Foetus. — The functions of the foetus are in the 
main the same, with differences depending on the situation in which 
it is placed, as those of the separate being. It breathes, it is 
nourished, it forms secretions, and its nervous system acts. The 
mode in which some of these functions are carried on in intra-uterine 
life requires separate consideration. 

1. Nutrition. — 'During the early period of pregnancy, and before 
the formation of the umbilical vesicle and the allantois, it is certain 

1 Obst. Trans, vol. xiii. p. 216. 



ANATOMY AXD PHYSIOLOGY OF THE FCETUS. 117 

that nutritive material must be supplied to the ovum by endosmosis 
through its external envelope. The precise source, however, from 
which this is obtained is not positively known. By some it is 
believed to be derived from the granulations of the discus proligerus 
which surround it as it escapes from the Graafian follicle, and sub- 
sequently from the layer of albuminous matter which surrounds the 
ovum before it reaches the uterus; while others think it probable 
that it may come from a special liquid secreted by the interior of 
the Fallopian tube as the ovum passes along it. As soon as the 
ovum has reached the uterus, there is every reason to believe that 
the umbilical vesicle is the chief source of nourishment to the embryo, 
through the channel of the omphalo- mesenteric vessels, which convey 
matters absorbed from the interior of the vesicle to the intestinal 
canal of the foetus. At this time the exterior of the ovum is covered 
by the numerous fine villosities of the primitive chorion, which are 
imbedded in the mucous membrane of the uterus, and it is thought 
that they may absorb materials from the maternal system, which may 
be either directly absorbed by the embryo, or which may serve the 
purpose of replacing the nutritive matter which has been removed 
from the umbilical vesicle by the omphalo-mesenteric vessels. This 
point it is, of course, impossible to decide. Joulin, however, thinks 
that these villi probably have no direct influence on the nourishment 
of the foetus, which is at this time solely effected by the umbilical 
vesicle, but that they absorb fluid from the maternal system, which 
passes through the amnion and forms the liquor amnii. As soon as 
the allantois is developed, vascular communication between the foetus 
and the maternal structures is established, and the temporary func- 
tion of the umbilical vesicle is over ; that structure, therefore, rapidly 
atrophies and disappears, and the nutrition of the foetus is now solely 
carried on by means of the chorion villi, lined as they now are by 
the vascular endo-chorion, and chiefly by those which go to form the 
substance of the placenta. 

This statement is opposed to the views of many physiologists, who 
believe that a certain amount of nutritive material is conveyed fco 
the foetus through the channel of the liquor amnii, itself derived 
from the maternal system, which is supposed either to be absorbed 
through the cutaneous surface of the foetus, or carried to the intesti- 
nal canal by deglutition. Tin- reasons for assigning to the Liquor 
amnii a nutritive function are, however, so slight, thai it is dimcull 
to believe that, it has any appreciable action in this way. They are 
based on some questionable observations, such as those of Weydlich, 
who kept a calf alive for fifteen days by feeding it Bolely on liquor 
amnii. and the experiments of Burdach, who found the cutaneous 
lymphatics engorged in a foetus removed from the amniotic cavity, 
while those of the intestine were empty. 'Flic deglutition of the 
liquor amnii lor the purposes of nutrition, has hen assumed from its 
occasional detection in the stomach of the foetus, the presence of 
which may, however, be readily explained by spasmodic efforts al 
respiration, which the foetus undoubtedly often makes before birth, 
especially when the placental circulation is in any way interfered with, 



118 PEEGNANCY 






and during which a certain quantity of fluid would necessarily be 
swallowed. The quantity of nutritive material, moreover, in the 
liquor amnii is so small — not more than 6 to 9 parts of albumen in 
1000 — that it is impossible to conceive how it could have any 
appreciable influence in nutrition, even if its absorption, either by the 
skin or stomach, were susceptible of proof. 

That the nutrition of the foetus is effected through the placenta 
is proved by the common observation that whenever the placental 
circulation is arrested, as by disease of its structure, the foetus atro- 
phies and dies. The precise mode, however, in which nutritive 
materials are absorbed from the maternal blood is still a matter of 
doubt, and must remain so until the mooted points as to the minute 
anatomy of the placenta are settled. The various theories enter- 
tained on this subject by the upholders of the Hunterian doctrine of 
placental anatomy, and by those who deny the existence of a sinus 
system, have been already referred to in the chapter on the Anatomy 
of the Placenta, to which the reader is referred (pp. 104-6). 

2. Respiration. — One of the chief functions of the placenta, besides 
that of nutrition, is the supply of oxygenated blood to the foetus. 
That this is essential to the vitality of the foetus, and that the pla- 
centa is the site of oxgyenation, are shown by the facts that when- 
ever the placenta is separated, or the access of foetal blood to it 
arrested by compression of the cord, instinctive attempts at inspira- 
tion are made, and if aerial respiration cannot be performed, the foetus 
is expelled asphyxiated. Like the other functions of the foetus during 
intra-uterine life, that of respiration has been made the subject of 
numerous more or less ingenious hypotheses. Thus many have 
believed that the foetus absorbed gaseous material from the liquor 
amnii, which served the purpose of oxygenating its blood, St. Hilaire 
thinking that this was effected by minute openings in its skin, 
Beclard and others through the bronchi, to which they believed the 
liquor amnii gained access. Independently of the entire want of 
evidence of the absorption of gaseous materials by these channels, 
the theory is disproved by the fact that the liquor amnii contains no 
air which is capable of respiration. Serres attributed a similar func- 
tion to some of the chorion villi, which he believed penetrated the 
utricular glands of the decidua reflexa, and absorbed gas from the 
hydroperione, or fluid situated between it and the decidua vera, and 
in this manner he thought the foetal blood was oxygenated until the 
fifth month of intra-uterine life, when the placenta was fully formed. 
This hypothesis, however, rests on no accurate foundation, for it is 
certain that the chorion villi do not penetrate the utricular glands 
in the manner assumed ; or, even if they did, the mode in which the 
oxygen thus absorbed by the chorion villi reaches the foetus, which 
is separated from them by the amnion and its contents, would still 
remained unexplained. 

The mode in which the oxygenation of the foetal blood is effected 
before the formation of the placenta remains, therefore, as yet un- 
known. After the development of that organ, however, it is less 
difficult to understand, for the foetal blood is everywhere brought 



ANATOMY AXD PHYSIOLOGY OF THE F03TIJS. 119 

into such close contact with the maternal, in the numerous minute 
ramifications of the umbilical vessels, that the interchange of gas >s 
can readily be effected. The activity of respiration is doubtless much 
less than in extra-uterine life, for the waste of tissue in the foetus is 
necessarily comparatively small, from the fact of its being suspended 
in a fluid medium of its own temperature, and from the absence of 
the processes of digestion and of respiratory movements. The quan- 
tity of carbonic acid formed would, therefore, be much less than after 
birth, and there would be a correspondingly small call for oxygena- 
tion of venous circulation. 

3. Circulation. — The functions of the lungs being in abeyance, it 
is necessary that all the foetal blood should be carried to the placenta 
to receive oxygen and nutritive materials. To understand the mode 
in which this is effected, we must bear in mind certain peculiarities 
in the circulatory system which disappear after birth. 

1. The two sides of the foetal heart are not separate, as in the 
adult. The right ventricle in the adult sends also the venous blood 
to the lungs, through the pulmonary arteries, to be aerated by con- 
tact with the atmosphere. In the foetus, however, only sufficient 
blood is passed through the pulmonary arteries to insure their being 
pervious and ready to carry blood to the lungs immediately after 
birth. 

An aperture of communication, the foramen ovale, exists between 
the two auricles, which is arranged so as to permit the blood reach- 
ing the right auricle to pass freely into the left, 
but not vice versa. By this means a large portion Fig. en. 

of the blood reaching the heart through the venae 
cavse, instead of passing, as in the adult, into the 
right ventricle, is directed into the left auricle. 

2. Even with this arrangement, however, a 
larger portion of blood would pass into the pul- 
monary arteries than is required for transmission 
to the lungs, and a further provision is made to 
prevent its going to them by means of a foetal 
vessel, the ductus arteriosus (Fig. 66), which arises Diagram of Fatal n 
from the point of bifurcation of the pulmonary < A,ter Daiton.) 
arteries, and opens into the arch of the aorta. I' p°|" ta ' 

r , 2. riiiiimnarv artery. 

In consequence of this arrangement only a very 3|3 . Pni m0 nary i..-, 
small portion of the blood reaches the lungs at 4. Ductus arteriosus. 
all. 

3. The foetal hypogastric arteries are continued into two large 
arterial trunks, which, passing into the cord, form the umbilical 
arteries, and carry the impure foetal blood into the placenta. 

4. The purified blood is collected into the single umbilical vein, 
through which it is carried to the under surface of the liver, from 
which point it is conducted, by means of another special foetal v. 

the ductus venosus, into the ascending vena cava, and the righl 
auricle. 

Course of the Fa-fa! Circulation.— In order to understand the course 
of the foetal blood, it may be mosl conveniently traced from the point 




120 PREGNANCY. 

where it reaches the under surface of the liver through the umbilical 
vein. Part of it is distributed to the liver itself, but the greater 
quantity is carried directly into the vena cava, through the ductus 
venosus. The vena cava also receives the blood from the foetal veins 
of the lower extremities, and that portion of the blood of the um- 
bilical vein which has passed through the liver. This mixed blood 
is carried up to the right auricle, from which by far the greater part 
of it is immediately directed into the left auricle, through the fora- 
men ovale. From thence it passes into the left ventricle, which sends 
the greater part of it into the head and upper extremities through 
the aorta, a comparatively small quantity being transmitted to the 
inferior extremities. The blood which is thus sent to the upper part 
of the body is collected into the vena cava superior, by which it is 
thrown into the right auricle. Here the mass of it is probably di- 
rected into the right ventricle, which expels it into the pulmonary 
arteries, and from thence through the ductus arteriosus into the 
descending aorta. By this arrangement it will be seen that the de- 
scending aorta conveys to the lower part of the body the compara- 
tively impure blood which has already circulated through the head, 
neck, and upper extremities. From the descending aorta a small 
quantity of blood is conveyed to the lower extremities, the greater 
part of it being carried for purification to the placenta through the 
umbilical arteries. 

Establishment of Independent Circulation.— As soon as the child is 
born it generally cries loudly, and inflates its lungs, and, in conse- 
quence, the pulmonary arteries are dilated, and the greater portion 
of the blood of the right ventricle is at once sent to the lungs, from 
whence, after being arterialized, it is returned to the left auricle, 
through the pulmonary veins. The left auricle, therefore, receives 
more blood than before, the right less, and the placental circulation 
being arrested, no more passes through the umbilical vein. In con- 
sequence of this, the pressure of the blood in the two auricles is 
equalized, the mass of the blood in the right auricle no longer passes 
into the left (the valve of the foramen ovale being closed by the 
equal pressure on both sides), but directly into the right ventricle, 
and from thence into the pulmonary arteries, and the ductus arte- 
riosus soon collapses and becomes impervious. The mass of blood in 
the descending aorta no longer finds its way into the hypogastric 
arteries, but passes into the lower extremities, and the adult circula- 
tion is established. 

Changes after Birth. — The changes which take place in the tempo- 
rary vascular arrangements of the foetus, prior to their complete dis- 
appearance, are of some practical interest. The ductus arteriosus, 
as has been said, collapses, chiefly because the mass of blood is drawn 
to the lungs, and partly, perhaps, by its own inherent contractility. Its 
walls are found to be thickened, and its canal closes, first in the centre, 
and subsequently at its extremities, its aortic end remaining longer per- 
vious on account of the greater pressure of blood from the left side of 
the heart (Fig. 67). Practical closure occurs within a few days after 



ANATOMY AND PHYSIOLOGY OF THE FCETUS 



121 




Diagram of Heart of Infant. 
(After Dalton.) 

1. Aorta. 2. Pulmonary Artery. 
3, 3. Pulmonary branches. 4. Duc- 
tus arteriosus becoming obliterated. 



birth, although Flourens states that it is Fig. 67. 

not completely obliterated until eighteen 
months or two years have elapsed. 1 Ac- 
cording to Schroeder, its walls unite with- 
out the formation of any thrombus. The 
foramen ovale is soon closed by its valve, 
which contracts adhesion with the edges 
of the aperture, so as effectually to occlude 
it. Sometimes however, a small canal of 
communication between the two auricles 
may remain pervious for many months, or 
even a year and more, without, however, 
any admixture of blood occurring. A 
permanently patulous condition of this 
aperture, however, sometimes exists, 
giving rise to the disease known as 
cyanosis. 

The umbilical arteries and veins, and the ductus venosus soon also 
become impermeable, in consequence of concentric hypertrophy of 
their tissues and collapse of their walls. The closure of the former 
is aided by the formation of coagula in their interior. According to 
Eobin, a longer time than is usually supposed elapses before they 
become completely closed, the vein remaining pervious until the 
twentieth or thirtieth day after delivery, the arteries for a month or 
six weeks. He has also described 2 a remarkable contraction of the 
umbilical vessels within their sheaths, at the point where they leave 
the abdominal walls, which takes place within three or four days 
after birth, and seems to prevent hemorrhage taking place when the 
cord is detached. 

Function of the Liver. — The liver, from its proportionately large 
size, apparently plays an important part in the foetal economy. It 
is not until about the fifth month of utero-gestation that it assu] 
its characteristic structure, and forms bile, previous to thai time Its 
texture being soft and undeveloped. According to Claude Bernard. 
after this period one of its most important offices is the formation of 
sugar, which is found in much larger amount in the foetus than after 
birth. Sugar is, however, found in the f'o-tal structures long before 
the development of the liver, especially in the mucous and cutaneous 
tissues, and it seems probable thai these, as well as the placenta itself, 
then fulfil the glycogenic function, afterwards chiefly performed by 
the liver. The bile is secreted after the fifth month of pregnancy, 
and passes into the intestinal canal and is subsequently collected in 
the gall-bladder. By some physiologists it has been supposed thai 
the liver, during intra-uterine life, was the chief seal of aepuration 
of the carbonic acid contained in the venous blood of the foetus. It 
is, however, more generally believed thai this is accomplished solely 
in the placenta. The bile, mixed with the mucous secretion of 1 



Aead. 

9 



dea Sciences, 1 854, 



-' Acad, dee Sciences, I860. 



122 PREGNANCY. 

intestinal tract, forms the meconium which is contained in the intes- 
tines of the foetus, and which collects in them during the whole period 
of intra-uterine life. It is a thick, tenacious, greenish substance, 
which is voided soon after birth in considerable quantity. 

The Urine. — Urine is certainly formed during intra-uterine life, 
as is proved by the fact familiar to all accoucheurs, that the bladder 
is constantly emptied instantly after birth. It has generally been 
supposed that the foetus voided its urine into the cavity of the am- 
nion, and the existence of traces of urea in the liquor amnii, as well 
as some cases of imperforate urethra, in which the bladder was found 
to be enormously distended, and some congenital hydronephrosis 
associated with impervious ureters, have been supposed to corrobo- 
rate this assumption. The question has been very fully studied by 
Jonlin, who has collected together a large number of instances in 
which there was imperforate urethra without any undue distension 
of the bladder. He holds also that the amount of urea fonnd in the 
liquor amnii is far too minute to justify the conclusion that the urine 
of the foetus was habitually poured into it, although a small quantity 
may, he thinks, escape into it from time to time ; and he, therefore, 
believes that the urine of the foetus is only secreted regularly and 
abundantly after birth, and that during intra-uterine life its retention 
is not likely to give rise to any functional disturbance. 1 

Function of the Nervous System. — There is no doubt that the 
nervous system acts to a considerable extent during intra-uterine 
life, and some authors have even s apposed that the foetus was en- 
dowed with the power of making instinctive or voluntary movements 
for the purpose of adapting itself to the form of the uterine cavity. 
There can be no question, however, that the movements the foetus 
performs are purely reflex and automatic. That it responds to a 
stimulus applied to the cutaneous nerves is proved by the experi- 
ments of Tyler Smith, who laid bare the amnion in pregnant rabbits, 
and found that the foetus moved its limbs when these were irritated 
through it. Pressure on the mother's abdomen, cold applications, 
and similar stimuli, will also produce energetic foetal movements. 
The gray matter of the brain in the new-born child is, however, quite 
rudimentary in its structure, and there is no evidence of intelligent 
action of the nervous system until some time after birth, and a fortiori 
during pregnancy. 

1 Acad, des Sciences, p. 301. 



PREGNANCY. 123 



CHAPTEE III. 

PREGNANCY. 

As soon as conception has taken place a series of remarkable 
changes commence in the uterus, which progress nntil the termina- 
tion of pregnancy, and are well worthy of careful study. They produce 
those marvellous modifications which effect the transformation of the 
small undeveloped uterus of the non-pregnant state into the large 
and full}- developed uterus of pregnancy, and have no parallel in the 
whole animal economy. 

A knowledge of them is essential for the proper comprehension 
of the phenomena of labor, and for the diagnosis of pregnancy which 
the practitioner is so frequently called upon to make. Excluding 
the varieties of abnormal pregnancy, which will be noticed in an- 
other place, we shall here limit ourselves to a consideration of the 
modifications of the maternal organism which result from simple 
and natural gestation. 

Changes in the Uterus. — The unimpregnated uterus measures 2 J 
inches in length, and weighs about 1 oz., while at the full term of 
pregnancy it has so immensely grown as to weigh 24 ozs., and meas- 
ure 12 inches. This growth commences as soon as the ovum reaches 
the uterus, and continues uninterruptedly until delivery. In the 
early months the uterus is contained entirely in the cavity of the 
pelvis, and the increase of size is only apparent on vaginal exam i na- 
tion, and that with difficulty. After the third month the enlarge- 
ment is chiefly in the lateral direction, so that the whole body of the 
uterus assumes more of a spherical shape than in the non-pregnant 
state. If an opportunity of examining the gravid uterus post-mor- 
tem should occur at this time, it will be found to have the form <>[' a 
sphere flattened somewhat posteriorly, and bulging anteriorly. 

After tin- ascent of the organ into the abdomen, it develops more 
in the vertical direction, so that at term it lias the form of an ovoid, 
with its large extremity above and its narrow end a1 the cervix uteri, 
and its Longitudinal axis corresponds to the long diameter of tin 1 
mother's abdomen, provided the presentation be either of the bead 
or breach. The anterior surface is now even more distinctly pro- 
jecting than before — a fad which is explained by the proximity of 
the posterior surface to the rigid spinal column behind, while the 
anterior is in relation with the lax abdominal parietes, which yield 
readily to pressure, and so allow of the more marked prominence oi 
the anterior uterine wall. 

Change in Situation. — Before the gravid uterus has risen ou1 of the 
pelvis no appreciable increase in the size of the abdomen is percep- 
tible. On the contrary, i1 is an old observation that at this ea 



124 



PREGNANCY 



Fig. 68. 



stage of pregnancy the abdomen is flatter than usual, on account of 
the partial descent of the uterus in the pelvic cavity as a result of its 
increased weight. As the growth of the organ advances it soon be- 
comes too large to be contained any longer within the pelvis, and 
about the middle of the third or the beginning of the fourth month 
the fundus rises above the pelvic brim — not suddenly, as is often 
erroneously thought, but slowly and gradually — when it may be felt 
as a smooth rounded swelling. 

Size at various Periods of Pregnancy. — It is about this time that 
the movements of the foetus first become appreciable to the mother, 
when " quickening" is said to have taken place. Towards the end of 
the fourth month the uterus reaches to about three fingers' breadth 
above the symphysis pubis. About the fifth month it occupies the 
hypogastric region, to which it imparts a marked projection, and the 
alteration in the figure is now distinctly perceptible to visual exami- 
nation. About the sixth month it is on a level with, or a little 
above, the umbilicus. About the seventh month it is about two 
inches above the umbilicus, which is now projecting and prominent, 
instead of depressed, as in the non-pregnant state. During the eighth 
and ninth months it continues to increase until the summit of the 
fundus is immediately below the ensiform cartilage (Fig. 68). A 

knowledge of the size of the uterine 
tumor at various periods of preg- 
nancy, as thus indicated, is of consid- 
erable practical importance, as form- 
ing the only guide by which we can es- 
timate the probable period of delivery 
in certain cases in which the usual 
data for calculation are absent, as, for 
example, when the patient has con- 
ceived during lactation. 

The Uterus Sinks before Delivery. 
■ — For about a week or more before 
labor the uterus generally sinks some- 
what into the pelvic cavity, in con- 
sequence of the relaxation of the soft 
parts which precedes delivery, and 
the patient now feels herself smaller 
and lighter than before. This change 
is familiar to all child-bearing women, 
to whom it is known as "the lighten- 
ing before labor." 

The Direction of the Uterus. — While 
the uterus remains in the pelvis its 
longitudinal axis varies in direction, much in the same way as that 
of the non-pregnant uterus, sometimes being more or less vertical, 
at others in a state of ante version or partial retroversion. These 
variations are probably dependent on the distension or emptiness of 
the bladder, as its state must necessarily affect the position of the 
movable organ poised behind it. After the uterus has risen into the 




Size of Uterus at various Periods of 
Pregnancy. 



PREGNANCY. 12o 

abdomen its tendency is to project forwards against the abdominal 
wall, which forms its chief support in front. In the erect position 
the long axis of the uterine tumor corresponds with the axis of the 
pelvic brim, forming an angle of about 30° with the horizon. In the 
semi-recumbent position, on the other hand, as Duncan 1 has pointed 
out, its direction becomes much more nearly vertical. In women who 
have borne many children, the abdominal parietes no longer afford 
an efficient support, and the uterus is displaced anteriorly, the fundus 
in extreme cases even hanging downwards. 

Lateral Obliquity of the Uterus. — In addition to this anterior ob- 
liquity, on account of the projection of the spinal column, the uterus 
is very generally also displaced laterally, and sometimes to a very 
marked degree, so that it may be felt entirely in one flank, instead 
of in the centre of the abdomen. In a large proportion of cases this 
lateral deviation is to the right side, and many hypotheses have 
been brought forward to explain this fact, none of them being satis- 
factory. Thus, it has been supposed to depend on the greater fre- 
quency with which women lie on their right side during sleep, on the 
greater use of the right leg during walking, on the supposed com- 
parative shortness of the right round ligament, which drags the 
tumor to that side, or on the frequent distension of the rectum on the 
left side, which prevents the uterus being displaced in that direction. 
Of these the last is the cause which seems most constantly in opera- 
tion, and most likely to produce the effect. 

Changes in the Direction of the Cervix. — The cervix must obviously 
adapt itself to the situation of the body of the uterus. We find, 
therefore, that in the early months, when the uterus lies low in the 
pelvis, it is more readily within reach. After the ascent of the 
uterus, it is drawn up, and frequently so much so as to be reached 
with difficulty. When the uterus is much anteverted, as is so often 
the case, the os is displaced backwards, so that it cannot be felt at 
all by the examining finger. 

ition of the Uterus to the Surrounding Parts. — Towards the end 

sgnaney the greater part of the anterior surface of the uterus is 

in contact with the abdominal wall, its lower portion resting on the 

rior surface of the symphysis pubis. The posterior Burface 
on the spinal column, while the small intestines are pushed to either 
side, the large intestines surrounding the uterus like an arch. 

Changesinthi Uterine Parietes.— The great distension of the uterus 
during pregnancy was formerly supposed to be mainly due to the 
mechanical pressure of the enlarging ovum within it. If this were 
so. then the uterine walls would be necessarily much thinner than in 
the non-pregnant state. This is well known not to be the case, and 
the immense increase in the size of the ut«-rin<- cavity is to be ex- 
plained by tin- hypertrophy of its walls. At the full period of preg- 
nancy the thickness of the uterine pariet snerally about the 
same as thai of the non-pregnant uterus, rather more at the placental 
site, and less in the neighborhood of the cervix. T eir 1 

: Researches in ( Obstetrics, p. i 0. 



126 



PREGNANCY. 



however, varies in different cases, and in some women they are so 
thin as to admit of the foetal limbs being very readily made out by 
palpation. Their density is, however, always much diminished, and, 
instead of being hard and inelastic, they become soft and yielding to 
pressure. This change coincides with the commencement of preg- 
nancy, of which it forms, as recognizable in the cervix, one of the 
earliest diagnostic marks. At a more advanced period it is of value 
as admitting a certain amount of yielding of the uterine walls to 
the movements of the foetus, thus lessening the chance of their being 
injured. 

Changes in the Cervix during Pregnancy. — Very erroneous views 
have long been taught, in most of our standard works on midwifery, 
as to the changes which occur in the cervix uteri during pregnancy. 
It is generally stated that, as pregnancy advances, the cervical cavity 
is greatly diminished in length, in consequence of its being gradually 
drawn up so as to form part of the general cavity of the uterus, so 
that in the latter months it no longer exists. In almost all midwifery 
works accurate diagrams are given of this progressive shortening of 
the cervix (Figs. 69 to 72). The cervix is generally described as 

Figs. 69, 70, 71, 72. 






Supposed Shortening of the Cervix at the Third, Sixth, Eighth, and Ninth Months of Pregnancy, as 

Figured in Obstetric Works. 

having lost one-half of its length at the sixth month, two- thirds at 
the seventh, and to be entirely obliterated in the eighth and ninth. 
The correctness of these views was first called in question in recent 
times by Stoltz, in 1826, but Dr. Duncan, 1 in an elaborate historical 
paper on the subject, has shown that Stoltz was anticipated by Weit- 
brech in 1750, and, to a less degree, by Eoederer and other writers. 
This opinion is now pretty generally admitted to be correct, and is 
upheld by Cazeaux, Arthur Farre, Duncan, and most modern obstet- 
ricians. Indeed, various post-mortem examinations in advanced 
pregnancy have shown that the cavity of the cervix remains in 



1 Researches in Obstetrics. 



PREGNANCY 



127 



reality of its normal length of one inch, and it can often be measured 
during life by the examining finger, on account of its patulous state 
(Fig. 73). During the fortnight immediately preceding delivery, 
however, a real shortening or obliteration of the cervical cavity takes 



Fig. 73. 




Cervix from a Woman Dyiug in the Eighth Mouth of Pregnancy. (After Duucan.) 

place; but this, as Duncan has pointed out, seems to be due to the 
incipient uterine contractions, which prepare the cervix for labor. 

Apparent Shortening. — There is, no doubt, an apparent shortening 
of the cervix always to be detected during pregnancy, but this is a 
fallacious and deceptive feeling, due to the softness of the tissue 
the cervix, which is exceedingly characteristic of pregnancy, and 
which to an experienced finger affords one of its besl diagnostic 
marks. 

Softening of the Cervix. — In the non-pregnant state the tissue of 
the cervix is hard, firm, and inelastic. When conception occurs, 
softening begins at the external OS, and pr< tceeds gradually and slowly 
upwards until it involves the whole of the cervix. By the end of 
the fourth month both lips of the os are thick, softened, and velvety 
to the touch, giving a sensation, likened by Cazeaux to that produced 
by pressing or a table through a thick, sofl cover. By the sixth 
month at leasl one-half of the cervix is thus altered, and by the 

eighth the whole of it, and SO much so that at this time those nnac- 

customed to vaginal examination experience Bome difficulty in dis- 
tinguishing it from the vaginal walls. It is this Boftening, then, 
which gives rise to the apparent shortening of the cervix 
rally described, and it is an invariable concomitanl of pregnancy 



128 PREGNANCY. 

except in some rare cases in which, there has been antecedent morbid 
induration and hypertrophic elongation of the cervix. If, therefore, 
on examining a woman supposed to be advanced in pregnancy, we 
find the cervix to be hard and projecting into the vaginal canal, we 
may safely conclude that pregnancy does not exist. The existence 
of softening, however, it must be remembered, will not of itself 
justify an opposite conclusion, as it may be produced, to a very con- 
siderable extent, by various pathological conditions of the uterus. 

The Os Uteri is generally Patulous. — At the same time that the 
tissue of the cervix is softened, its cavity is widened, and the external 
os becomes patulous. This change varies considerably in primiparge 
and multiparas. In the former the external os often remains closed 
until the end of pregnancy ; but even in them it generally becomes 
more or less patulous after the seventh month, and admits the tip of 
the examining finger. In women who have borne children this 
change is much more marked. The lips of the external os are in 
them generally fissured and irregular, from slight lacerations of its 
tissue in former labors. It is also sufficiently open to admit the tip 
of the finger, so that in the latter months of pregnancy it is often 
quite possible to touch the membranes, and through them to feel the 
presenting part of the child. 

Changes in the Texture of the Uterine Tissues. — The remarkable 
increase in size of the uterus during pregnancy is, as we have seen, 
chiefly to be explained by the growth of its structures, all of which' 
are modified during gestation. The peritoneal covering is consider- 
ably increased, so as still to form a complete covering to the uterus 
when at its largest size. William Hunter supposed that its extension 
was affected rather by the unfolding of the layers of the broad liga- 
ment, than by growth. That the layers of the broad ligament do 
unfold during gestation, especially in the early months, is probable ; 
but this is not sufficient to account for the complete investment of 
the uterus, and it is certain that the peritoneum grows pari passu 
with the enlargement of the uterus. In addition there is a new for- 
mation of fibrous tissue between the peritoneal and the muscular 
coats, which affords strength, and diminishes the risk of laceration 
during labor. 

Muscular Coat. — The hypertrophy of the muscular tissue of the 
uterus is, however, the most remarkable of the changes produced by 
pregnancy. Not only do the previously-existing rudimentary fibre- 
cells become enormously increased in size — so as to measure, accord- 
ing to Kolliker, from seven to eleven times their former length, and 
from two to five times their former breadth — but new unsiriped 
fibres are largely developed, especially in the inner layers. These 
new cells are chiefly found in the first months of pregnancy, and 
their growth seems to be completed by the sixth month. The con- 
nective tissue between the muscular layers is also largely increased 
in amount. The weight of the muscular tissue of the gravid uterus 
is, therefore, much increased, and it has been estimated by Heschl 
that it weighs at term from 1 to 1.5 lbs., that is, about sixteen times 
more than in the unimpregnated state. This great development of 



PREGNANCY. 129 

the muscular tissue admits of its dissection in a way which is quite 
impossible in the unimpregnated state, aud the recent researches of 
Helie (p. 53) enable us to understand much better than before how 
the muscles forming the walls of the gravid uterus act during the 
expulsion of the child. 

The changes in the mucous coat of the uterus, which result in the 
formation of the decidua, have already been discussed at length else- 
where (p. 89). 

Circulatory Apparatus. — The circulatory apparatus of the uterus 
during pregnancy has been described when the anatomy of the 
placenta was under consideration (p. 103). 

Lymphatics. — The lymphatics are much increased in size ; and re- 
cent theories on the production of certain puerperal diseases attribute 
to them a more important action than has been commonly assigned 
to them. 

Nerves. — The question of the growth of the nerves has been hotly 
discussed. Eobert Lee took the foremost place among those who 
maintain that the nerves of the uterus share the general growth of 
its other constituent parts. Dr. Snow Beck, however, believed that 
they remain of the same size as in the unimpregnated state, and this 
view is supported by Hirschfeld, Robin, and other recent writers. 
Robin thought that there was an apparent increase in the size of the 
nerve-tubes, which, however, is really due to increase in the neuri- 
lemma. Kilian describes the nerves as increasing in length but not 
in thickness: while Schroeder states that they participate equally 
with the lymphatics in the enlargement the latter undergo. Which- 
ever of these views may ultimately be found to be correct, it is cer- 
tain that analogy would lead us to expect an increase of nervous as 
well as of vascular, supply. 

General Modification in the Body produced by Pregnancy. — Tt is not 
in the uterus alone, that pregnancy is found to produce modifications 
of importance. There are few of the more important functions of 
the body which arc not, to a greater or less extent, affected : to some 
of these it is necessary briefly to direct attention, inasmuch as. when 
carried to exec—, they produce those disorders which often compli- 
cate gestation, and which prove so distressing and even dangerous 
to the patients. Such of them as arc apparent and may aid us in 
diagnosis are discussed in the chapter which treats of the Bigns and 
symptoms of pregnancy ; in this place it is only necessary to refer to 
those which do not properly fall into thai category. 

Changes in the Blood. — Amongsl those which are most constant 
and important arc the alterations in the composition of the blood. 
The opinion of the profession on this subject lias, of late years, under- 
gone a remarkable change. Formerly it was universally believed 
that pregnancy was, as the rule, associated with a condition analagous 
to plethora, and that this explained many characteristic phenomena 
of common occurrence, such as headache, palpitation, singing in 
ears, shortness of breadth, and the like. A- ;i consequence il 
the habitual custom, not yet by any means entirely abandons 
treat pregnant women on an antiphl them on 



130 PREGNANCY. 

low diet, to administer lowering remedies, and very often to practice 
venesection, sometimes to a surprising extent. Thus it was by no 
means rare for women to be bled six or eight times during the latter 
months, even when no definite symptoms of disease existed ; and 
many of the older authors record cases where depletion was practised 
every fortnight, as a matter of routine, and, when the symptoms 
were well marked, even from fifty to ninety times in the course of a 
single pregnancy. 

Composition of the Blood in Pregnancy. — Numerous careful analyses 
have conclusively proved that the composition of the blood during 
pregnancy is very generally — perhaps it would not be too much to 
say always — profoundly altered. Thus it is found to be more watery, 
its serum is deficient in albumen, and the amount of colored globules 
is materially diminished, averaging, according to the analyses of 
Becquerel and Rodier, 111.8 against 127.2 in the non-gravid state. 
At the same time the amount of fi brine and of extractive matter is 
considerably increased. The latter observation is of peculiar im- 
portance, as it goes far to explain the frequency of certain thrombotic 
affections, observed in connection with pregnancy and delivery ; this 
hyperinosis of the blood is also considerably increased after labor by 
the quantity of effete material thrown into the mother's system at 
that time, to be got rid of by her emunctories. The truth is, that 
the blood of the pregnant woman is generally in a state much more 
nearly approaching the condition of anaemia than of plethora, and it 
is certain that most of the phenomena attributed to plethora may be 
explained equally well and better on this view. These changes are 
much more strongly marked at the latter end of pregnancy than at 
its commencement, and it is interesting to observe that it is then that 
the concomitant phenomena alluded to are most frequently met with. 
Cazeaux, to whom we are chiefly indebted for insisting on the 
practical bearing of these views, contends that the pregnant state is 
essentially analogous to chlorosis, and that it should be so treated. 
Objection has not unnaturally been taken to this theory, as implying 
that a healthy and normal function is associated with a morbid state, 
and it has been suggested that this deteriorated state of the blood 
may be a wise provision of nature instituted for a purpose we are not 
as yet able to understand. It may certainly be admitted that preg- 
nancy, in a perfectly healthy state of the system, should not be 
associated with phenomena in themselves in any degree morbid. It 
must not be forgotten, however, that our patients are seldom, we 
might safely say never, in a state that is physiologically healthy. 
The influence of civilization, climate, occupation, diet, and a thousand 
other disturbing causes that, to a greater or less degree, are always 
to be met with, must not be left out of consideration. Making every 
allowance, therefore, for the undoubted fact that pregnancy ought to 
be a perfectly healthy condition, it must be conceded, I think, that 
in the vast majority of cases corning under our notice it is not entirely 
so ; and the deductions drawn by Cazeaux, from the numerous 
analyses of the blood of pregnant women, seem to point strongly to 
the conclusion that the general blood-state is one of poverty and 



PREGNANCY. 131 

anaemia, and that a depressing and antiphlogistic treatment is dis- 
tinctly contra-indicated. 

Modifications in certain Viscera. — Closely connected with the al- 
tered condition of the blood is the physiological hypertrophy of the 
heart, which is now well known to occur during pregnancy. This 
was first pointed out by Larcher in 1828, and it has been since veri- 
fied by numerous observers. It seems to be constant and considera- 
ble, and to be a purely physiological alteration intended to meet the 
increased exigencies of the circulation, which the complex vascular 
arrangements of the gravid uterus produce. The hypertrophy is 
limited to the left ventricle ; the right ventricle, as well as both au- 
ricles, being unaffected. Blot estimates that the whole weight of the 
heart increases one-fifth during gestation. The more recent re- 
searches of Lohlein 1 render it probable that the hypertrophy is less 
than these authors have supposed. According to Duroziez 2 the heart 
remains enlarged during lactation, but diminishes in size immediately 
after delivery in women who do not suckle, while in women who 
have borne many children it remains permanently somewhat larger 
than in nulliparae. Similar increase in the size of other organs has 
been pointed out by various writers, as, for example, in the lym- 
phatics, the spleen, and the liver. Tarnier states that in women who 
have died after delivery, the organs always show signs of fatty de- 
generation. According to Gassner the whole body increases in weight 
during the latter months of pregnancy, and this increase is somewhat 
beyond that which can be explained by the size of the womb and its 
contents. 

Formation of Osteophytes. — Irregular bony deposits between the 
skull and the dura mater, in some cases so largely developed as to 
line the whole cranium, have been so frequently detected in women 
who have died during parturition, thai they are believed by some to 
be a normal production connected with pregnancy. Ducresl found 
these osteophytes in more than one-third of the cases in which he 
performed post-mortem examinations during the puerperal period. 
Rokitansky, who corroborated the observation, believed this peculiar 
deposit of bony matter to be a physiological, and nol a pathological 
condition connected with pregnancy; bu1 whether it be so, or how 
it is produced, has no1 ye1 been satisfactorily determined. 

Changes in the Nervous System. More or less marked changes con- 
nected with the nervous system are generally observed in pregnancy, 
and sometimes to a very greal extent. When carried to excess they 
produce some of the mosl troublesome disorders which complicate 
gestation, such as alterations in the intellectual functions, changes in 
the disposition and character, morbid cravings, dizziness, neuralgia, 
syncope, and many others. Thej are purely functional in their cha- 
racter, and disappear rapidly after delivery, and may be besl de- 
scribed in connection with the disorders of pregnancy. 

changes in the Respiratory Organs, Respiration is often inter- 
fered with, from the mechanical results of the pressure of the en- 

1 Zeitschrift ftir Geburtehttlfe, etc., L876. ■ Ga«. dea BOpit. : 



132 PREGNANCY. 

larged uterus. The longitudinal dimensions of the thorax are 
lessened by the upward displacement of the diaphragm, and this 
necessarily leads to some embarrassment of the respiration, which 
is, however, compensated, to a great extent, by an increase in breadth 
of the base of the thoracic cavity. 

Changes in the Urine. — Certain changes, which are of very con- 
stant occurrence, in the urine of pregnant women have attracted 
much attention, and have been considered by many writers to be 
pathognomonic. They consist in the presence of a peculiar deposit, 
formed when the urine has been allowed to stand for some time, 
which has received the name of hiestein. Its presence was known 
to the ancients, and it was particularly mentioned by Savonarola in 
the fifteenth century, but it has more especially been studied within 
the last thirty j^ears by Eguisier, Grolding Bird, and others. If the 
urine of a pregnant woman be allowed to stand in a cylindrical ves- 
sel, exposed to light and air, but protected from dust, in a period, 
varying from two to seven days, a peculiar flocculent sediment, like 
fine cotton-wool, makes its appearance in the centre of the fluid, and 
soon afterwards rises to the surface and forms a pellicle, which has 
been compared to the fat on cold mutton -broth. In the course of a 
few days the scum breaks up and falls to the bottom of the vessel. 
On microscopic examination it is found to be composed of fat parti- 
cles, with crystals of ammoniaco-magnesium phosphates and phosphate 
of lime, and a large quantity of vibriones. These appearances are 
generally to be detected after the second month of pregnancy, and 
up to the seventli or eighth month, after which they are rarely pro- 
duced. Eegnauld explains their absence during the latter months 
of gestation by the presence in the urine, at that time, of free lactic 
acid, which increases its acidity, and prevents the decomposition of 
the urea into carbonate of ammonia. He believes that kiestein is 
produced by the action of free carbonate of ammonia on the phos- 
phate of lime contained in the urine, and that this reaction is pre- 
vented by the excess of acid. 

Grolding Bird believed kiestein to be analogous to casein, to the 
presence of which he referred it, and he states that he has found it 
in twenty-seven out of thirty cases. Braxton Hicks so far corrobo- 
rates his view, and states that the deposit of kiestein can be much 
more abundantly produced if one or two teaspoonfuls of rennet be 
added to the urine, since that substance has the property of coagu- 
lating casein. Much less importance, however, is now attached to 
the presence of kiestein than formerly, since a precisely similar sub- 
stance is sometimes found in the urine of the non-pregnant, especially 
in anaemic women, and even in the urine of men. Parkes states that 
it is not of uniform composition, that it is produced by the decompo- 
sition of urea, and consists of the free phosphates, bladder mucus, 
infusoria, and vaginal discharges. Neugebauer and Yogel give a 
similar account of it, and hold that it is of no diagnostic value. That 
it is of interest, as indicating the changes going on in connection with 
pregnancy, is certain ; but inasmuch as it is not of invariable occur- 
rence, and may even exist quite independently of gestation, it is 



SIGNS AND SYMPTOMS OF PREGNANCY. 133 

obviously quite undeserving of the extreme importance that lias been 
attached to it. 

[Although not a reliable test of pregnancy, it is a remarkable fact, 
that in all the cases of suspected impregnation in private practice in 
which we have employed it, Ave never found a woman pregnant who 
had not shown it in her urine. — Ed.] 



CHAPTEK IV. 

SIGNS AND SYMPTOMS OF PREGNANCY. 

Importance of the Subject. — In attempting to ascertain the presence 
or absence of pregnancy, the practitioner has before him a problem 
which is often beset with great difficulties, and on the proper solution 
of which, the moral character of his patient, as well as his own pro- 
fessional reputation, may depend. The patient and her friends can 
hardly be expected to appreciate the fact, that it is often far from 
easy to give a positive opinion on the point; and it is always advis- 
able to use much caution in the examination, and not to commit 
ourselves to a positive opinion, except on the most certain grounds. 
This is all the more important, because it is just in those cases in 
which our opinion is most frequently asked, that the statements of 
the patient are of least value, as she is either anxious to conceal the 
existence of pregnancy, or, if desirous of an affirmative diagnosis, 
unconsciously colors her statements, so as to bias the judgment of 
the examiner. 

Constant attempts have been made to classify the signs of preg- 
nancy; thus some divide them into the natural and sensible Bigns, 
others into the presumptive, the probable, and the certain. The latter 
classification, which is that adopted by Montgomery in his classical 
work on the "Signs and Symptoms of Pregnancy," is no doubl the 
better of the two, if any be required. The simplest way of studying 
the subject, however, is the one, now generally adopted, of considering 
the signs of pregnancy in the order in which they occur, and attaching 
to each an estimate of its diagnostic value 

Signs of a fruitful Conception.- From the earliesl ages authors 

have thought, thai the occurrence of concept] rrigh'1 be ascertained 

by certain obscure signs, such as a peculiar appearance <>f the ei 
swelling of the neck, or by unusual sensations connected with a 
fruitful intercourse. All of these, it need bardly be -aid, are far i<"> 
uncertain t<> he <>f the slightesl value. The lasl is a symptom od 
which many married women profess themselves able to depend, and 
one to which Cazeaux is inclined to attach some Importance. 



134 PREGNANCY. 

Cessation of Menstruation. — The first appreciable indication of 
pregnancy, on which any dependence can be placed, is the cessation 
of the customary menstrual discharge, and it is of great importance, 
as forming the only reliable guide for calculating the probable period 
of delivery. In women who have been previously perfectly regular, 
in whom there is no morbid cause which is likely to have produced 
suppression, the non-appearance of the catamenia may be taken as 
strong presumptive evidence of the existence of pregnancy; but it 
can never be more than this, unless verified and strengthened by 
other signs, inasmuch as there are many conditions besides pregnancy 
which may lead to its non-appearance. Thus exposure to cold, 
mental emotion, general debility, especially when connected with 
incipient phthisis, may all have this effect. Mental impressions are 
peculiarly liable to mislead in this respect. It is far from uncommon 
in newly-married women to find that menstruation ceases for one or 
more periods, either from the general disturbance of the system con- 
nected with the married life, or from a desire on the part of the 
patient to find herself pregnant. Also in unmarried women, who 
have subjected themselves to the risk of impregnation, mental emo- 
tion and alarm often produce the same result. 

Menstruation during Pregnancy. — A further source of uncertainty 
exists in the fact, that in certain cases menstruation may go on for 
one or more periods after conception, or even during the whole 
pregnancy. The latter occurrence is certainly of extreme rarity, 
but one or two instances are recorded by Perfect, Churchill, and 
other writers of authority, and therefore its possibility must be 
admitted. The former is much less uncommon, and instances of it 
have probably come under the observation of most practitioners. 
The explanation is now well understood. During the early months 
of gestation, when the ovum is not yet sufficiently advanced in growth 
to fill the whole uterine cavity, there is a considerable space between 
the decidua reflexa which surrounds it, and the decidua vera lining 
the uterine cavity. It is from this free surface of the decidua vera 
that the periodical discharge comes, and there is not only ample 
surface for it to come from, but a free channel for its escape through 
the os uteri. After the third month the decidua reflexa and the 
decidua vera blend together, and the space between them disappears. 
Menstruation after this time is, therefore, much more difficult to 
account for. It is probable that, in many supposed cases, occasional 
losses of blood from other sources, such as placenta prsevia, an abraded 
cervix uteri, or a small polypus, have been mistaken for true men- 
struation. If the discharge really occurs periodically after the third 
month, it can only come from the canal of the cervix. The occurrence, 
however, is so rare, that if a woman is menstruating regularly and 
normally, who believes herself to be more than four months advanced 
in pregnancy, we are justified ipso facto in negativing her supposition. 
In an unmarried woman all statements as to regularity of menstrua- 
tion are absolutely valueless, for, in such cases, nothing is more 
common than for the patient to make false statements for the express 
purpose of deception. 



SIGNS AND SYMPTOMS OF PREGNANCY. 135 

Pregnancy iclien Menstruation is Normally Absent. — Conception 
may unquestionably occur when menstruation is normally absent. 
This is far from uncommon in women during lactation, when the 
function is in abeyance, and who therefore have no reliable data for 
calculating the true period of their delivery. Authentic cases are 
also recorded in which young girls have conceived before menstrua- 
tion is established, and in which pregnancy has occurred after the 
change of life. 

Estimate of its Diagnostic Value. — Taking all these facts into ac- 
count, we can only look upon the cessation of menstruation as a fairly 
presumptive sign of pregnancy in women in whom there is no clear 
reason to account for it, but one which is undoubtedly of great value 
in assisting our diagnosis. 

Sympathetic Disturbances. — Shortl} 7 after conception various sym- 
pathetic disturbances of the system occur, and it is only very excep- 
tionally that these are not established. They are generally most 
developed in women of highly nervous temperament ; and the}' are, 
therefore, most marked in patients in the upper classes of society, in 
whom this class of organization is most common. 

Morning Sickness. — Amongst the most frequent of these are various 
disorders of the gastro-intestinal canal. Nausea or vomiting is very 
common ; and as it is generally felt on first rising from the recum- 
bent position, it is popularly known amongst women as the "morn- 
ing sickness." It sometimes commences almost immediately after 
conception, but more frequently not until the second month, and it 
rarely lasts after the fourth month. Generally there is nausea rather 
than actual vomiting. The woman feels sick and unable to eat her 
breakfast, and often brings up some glairy fluid. In other cases. Bhe 
actually vomits ; and sometimes the sickness is so excessive as to 
resist all treatment, seriously to affect the patient's health, and even 
imperil her life. These grave forms of the affection will require 
separate consideration. 

Cause of lb'' Sickness. — Very different opinions have been held as 
to the cause of morning sickness. Dr. Henry Bennel believes that, 
when at all severe, it is always associated with congestion and inflam- 
mation of the cervix uteri. Dr. (xraily Hewitt maintains that it de- 
pends entirely on flexion of the uterus, producing irritation of the 
uterine uerves a1 the seal of the flexion, and consequent sympathetic 
vomiting. This theory, when broached at the Obstetrical Societv, 
was received with little favor; it seems to me t<> he sufficiently dis- 
proved by the fact, which I believe to be certain, thai more or less 
nausea is a normal and nearly constanl phenomenon in pregnancy, 
for it is diflieult t<> believe that nearly every pregnanl woman ha- a 
flexed uterus. The generally received explanation is. probably, the 
correct one, viz., that nausea, as well as other forms or sympathetic 
disturbance, depend- on tin; Btretching of the uterine fibres 1>\ the 
growing ovum, and consequent irritation of tin' uterine nerves. It 
is, therefore, one, and only one, of the numerous reflex phenomena 
naturally accompanying pregnancy. It is an old observation that 
when the sickness of pregnancy is entirely absent, other, and gene- 



f 



136 PREGNANCY. 

rally more distressing, sympathetic derangements are often met with, 
such as a tendency to syncope. Dr. Bedford 1 has laid especial stress 
on this point, and maintains that under such circumstances Avomen 
are peculiarly apt to miscarry. 

Other derangements of the digestive functions, depending on the 
same cause, are not uncommon, such as excessive or depraved appe- 
tite, the patient showing a craving for strange and even disgusting 
articles of diet. These cravings may be altogether irresistible, and 
are popularly known as " longings." Of a similar character is the 
disturbed condition of the bowels frequently observed, leading to 
constipation, diarrhoea, and excessive flatulence. 

Other iSymjjathetic Phenomena. — Certain glandular sympathies may 
be developed, one of the most common being an excessive secretion 
from the salivary glands. A tendency to syncope is not infrequent, 
rarely proceeding to actual fainting, but rather to that sort of partial 
syncope, unattended with complete loss of consciousness, which the 
older authors used to call "lypothemia." This often occurs in women 
who show no such tendency at other times, and, when developed to 
any extent, it forms a very distressing accompaniment of pregnancy. 
Toothache is common, and is not rarely associated with actual caries 
of the teeth. When any of these phenomena are carried to excess it 
is more than probable that some morbid condition of the uterus 
exists, which increases the local irritation producing them. 

Mental Peculiarities. — Mental phenomena are very general. An 
undue degree of despondency, utterly beyond the patient's control, 
is far from uncommon ; or a change which renders the bright and 
good-tempered woman fractious and irritable ; or even the more for- 
tunate, but less common change, by which a disagreeable disposition 
becomes altered for the better. 

Diagnostic Value. — All these phenomena of exalted nervous suscep- 
tibility are but of slight diagnostic value. They may be taken as 
corroborating more certain signs, but nothing more; and they are 
chiefly interesting from their tendency to be carried to excess and to 
produce serious disorders. 

Mammary changes. — Certain changes in the mammas are of early 
occurrence, dependent, no doubt, on the intimate sympathetic rela- 
tions at all times existing between them and the uterine organs, but 
chiefly required for the purpose of preparing for the important func- 
tion of lactation, which, on the termination of pregnancy, they have 
to perform. 

Changes in the Areolee — Generally about the second month of preg- 
nancy the breasts become increased in size and tender. As preg- 
nancy advances they become much larger and firmer, and blue veins 
may be seen coursing over them. The most characteristic changes 
are about the nipples and areolee. The nipples become turgid, and 
are frequently covered with minute branny scales, formed by the 
dessication of sero-lactescent fluid oozing from them. The areolae be- 
come greatly enlarged and darkened from the deposit of pigment 

1 Diseases of Women and Children, p. 55 1» 



SIGNS AND SYMPTOMS OF PREGNANCY 



137 



(Fig. 74). The extent and degree of this discoloration vary much in 
different women. In fair women it may be so slight as to'be hardly 
appreciable ; while in dark women it is generally exceedingly charac- 
teristic, sometimes forming a nearly black circle extending over a 



Fig. 74. 




Appearance of the Areola in Pregnancy. 



great part of the breast. The areola becomes moist as well as dark 
in appearance and is somewhat swollen, and a number of small tuber- 
cles are developed upon it, forming a circle of projections around the 
nipple. These tubercles are described by Montgomery as being inti- 
mately connected with the lactiferous ducts, some of which may oc- 
casionally be traced into them and seem to open on their summits. 
As pregnancy advances they increase in size and Dumber. During 
the latter months what has been called "the secondary areola" is 
produced, and when well marked presents a very characteristic ap- 
pearance. It consists of a number of minute discolored spots all 
round the outer margin of the areola where the pigmentation is 
fainter, and which arc generally described as resembling spots from 
which the color had been discharged by a shower of water-drops. 
This change, like the darkening of the primary areola, is mosl marked 
in brunettes. At this period, especially in women whose skin is of 
fine texture, whitish silvery streaks are often Been on the l» r 
They arc produced by the stretching of the cutis \ era, and arc per- 
manent. 

By pressure on the breasts a small drop of serous-looking fluid 
can very generallv be pressed out from the nipple often as early as 
the third month, and on microscopic examination milk and oholos- 
trum globules can be seen in it. 
10 



138 PREGNANCY. 

Diagnostic Value of Mammary Changes. — The diagnostic value of 
these mammary changes has been variously estimated. When well 
marked they are considered by Montgomery to be certain signs of 
pregnancy. To this statement, however, some important limitations 
must be made. In women who have never borne children they, no 
doubt, are so ; for, although various uterine and ovarian diseases 
produce some darkening of the areola, they certainly never' produce 
the well-marked changes above described. In multiparas, however, 
the areolae often remain permanently darkened, and in them these 
signs are much less reliable. In first pregnancies the presence of 
milk in the breasts may be considered an almost certain sign, and it 
is one which I have rarely failed to detect even from a comparatively 
early period. It is true that there are authenticated instances of 
non-pregnant women having an abundant secretion of milk estab- 
lished from mammary irritation. Thus Baudelocque presented to 
the Academy of Surgery of Paris a young girl, eight years of age, 
who had nursed her little brother for more than a month. Dr. Tan- 
ner states — I do not know on what authority — 'that "it is not uncom- 
mon in Western Africa for young girls who have never been preg- 
nant to regularly employ themselves in nursing the children of others, 
the mammae being excited to action by the application of the juice 
of one of the euphorbiaceas." Lacteal secretion has even been noticed 
in the male breast. But these exceptions to the general rule are so 
uncommon as merely to deserve mention as curiosities ; and I have 
almost never been deceived in diagnosing a first pregnancy from the 
presence of even the minutest quantity of lacteal secretion in the 
breasts, although even then other corroborative signs should always 
be sought for. In multiparas the presence of milk is by no means 
so valuable, for it is common for milk to remain in the mammae long 
after the cessation of lactation, even for several years. Tyler Smith 
correctly says that " suppression of the milk in persons who are 
nursing and liable to impregnation is a more valuable sign of preg- 
nancy than the converse condition." This is an observation I have 
frequently corroborated. 

As a diagnostic sign, therefore, the mammary appearances are of 
great importance in primiparae, and when well marked they are sel- 
dom likely to deceive. They are specially important when we sus- 
pect pregnancy in the unmarried, as we can easily make an excuse 
to look at the breast without explaining to the patient the reason ; 
and a single glance, especially if the patient be dark-complexioned, 
may so far strengthen our suspicion as to justify a more thorough ex- 
amination. In married multiparas they are less to be depended upon. 
Other Pigmentary Changes. — In connection with this subject may 
be mentioned various irregular deposits of pigment which are fre- 
quently observed. The most common is a dark brownish or yellow- 
ish line starting from the pubes and running up to the centre of the 
abdomen, sometimes as far as the umbilicus only, at others forming 
an irregular ring round the umbilicus, and reaching to the epigas- 
trium. [It is well marked in pregnant women of the African race, 
even in those of quite a dark shade of skin. This line is narrower 



SIGNS AND SYMPTOMS OF PREGNANCY. 139 

as a rule, than in the white, but darker. — Ed.] It is, however, of 
very uncertain occurrence, being well marked in some women, while 
in others it is entirely absent. Patches of darkened skin are often 
observed about the face, chiefly on the forehead, and this bronzing 
sometimes gives a very peculiar appearance. Joulin states that it 
only occurs on parts of the face exposed to the sun, and that it is 
therefore most frequently observed in women of the lower order, 
who are freely exposed to atmospheric influences. These pigment- 
ary changes are of small diagnostic value, and may continue for a 
considerable time after delivery. 

Enlargement of the Abdomen. — The progressive enlargement of the 
abdomen, and the size of the gravid uterus at various periods of 
pregnancy, as well as the method of examination by means of ab- 
dominal palpation, have already been described (pp. 114 and 124). 

We will now consider the well-known phenomena produced by 
the movements of the foetus in utero, which are so familiar to all 
pregnant women. These, no doubt, take place from the earliest 
period of foetal life at which the muscular tissue of the foetus is suffi- 
ciently developed to admit of contraction, but they are not felt by 
the mother until somewhere about the sixteenth week of utero-ges- 
tation, the precise period at which they are perceived varying con- 
siderably in different cases. The error of the law on this subject, 
which supposes the child not to be alive, or " quick," until the mother 
feels its movements, is well known, and has frequently been protested 
against by the medical profession. The so-called quickening — which 
certainly is felt very suddenly by some women — is believed to depend 
on the rising of the uterine tumor sufficiently high to permit of the 
impulse of the foetus being transmitted to the abdominal walls of the 
mother, through the sensory nerves of which its movements become 
appreciable. The sensation is generally described as being a feeble 
fluttering, which, when first felt, not unfrequently causes unpleasant 
nervous sensations. As the uterus enlarges, the movements become 
more and more distinct, and generally consist of a series of sharp 
blows or kicks, sometimes quite appreciable to the naked eye, and 
causing distinct projections of the abdominal walls. Their force and 
frequency will also vary during pregnancy according to circum- 
stances. At times they are very frequent and distressing; at others, 
the foetus seems to be comparatively quiet, and they may even not 
be felt for several days in succession, and thus unnecessary fears as 
to the death of the foetus often arise. The state of the mother's 
health has an undoubted influence upon them. They arc said to 
increase in force after a prolonged abstinence from food, or in certain 
positions of the body. It is certain that causes interfering with the 
vitality of the foetus often produce very irregular and tumultuous 
movements. They can be very readily felt by the accoucheur on 
palpating the abdomen, and sometimes, in the latter months, so dis- 
tinctly as to leave no doubl as to the existence of pregnancy. They 
can also generally be induced by placing one hand on each aide of 
the abdomen and applying gentle pressure, which will induce foetal 
motion, that can be easilv appreciated. 



140 PREGNANCY. 

The Diagnostic Value of Foetal Movements. — As a diagnostic sign 
the existence of foetal movements has always held a high place, but 
care should be taken in relying on it. It is certain that women are 
themselves very often in error, and fancy they feel the movements 
of a foetus when none exists, being probably deceived by irregular 
contractions of the abdominal muscles, or flatus within the bowels. 
They may even involuntarily produce such intra-abdominal move- 
ments as may readily deceive the practitioner. Of course, in advanced 
pregnancy, when the foetal movements are so marked as to be seen as 
well as felt, a mistake is hardly possible, and they then constitute a 
certain sign. But in such cases there is an abundance of other indi- 
cations and little room for doubt. In questionable cases, and at an 
earlier period of pregnancy, the fact that movements are not felt 
must not be taken as a proof of the non-existence of pregnancy, for 
they may be so feeble as not to be perceptible, or they may be absent 
for a considerable period. 

Intermittent Uterine Contractions. — Braxton Hicks 1 has directed 
attention to the value, from a diagnostic point of view, of intermittent 
contractions of the uterus during pregnancy. After the uterus is 
sufficiently large to be felt by palpation, if the hand be placed over 
it, and it be grasped for a time without using any friction or pressure, 
it will be observed to distinctly harden in a manner that is quite 
characteristic. This intermittent contraction occurs every five or ten 
minutes, sometimes oftener, rarely at longer intervals. The fact that 
the uterus did contract in this way had been previously described, 
more especially by Tyler Smith, who ascribed it to peristaltic action. 
But it is certain that no one, before Dr. Hicks, had pointed out the 
fact that such contractions were constant and normal concomitants 
of pregnancy, continuing during the whole period of utero-gestation, 
and forming a read}^ and reliable means of distinguishing the uterine 
tumor from other abdominal enlargements. Since reading Dr. Hicks's 
paper I have paid considerable attention to this sign, which I have 
never failed to detect, even in the retroverted gravid uterus contained 
entirely in the pelvic cavity, and I am disposed entirely to agree 
with him as to its great value in diagnosis. If the hand be kept 
steadily on the uterus, its alternate hardening and relaxation can be 
appreciated with the greatest ease. The advantages which this sign 
has over the foetal movements are that it is constant, that it is not 
liable to be simulated by anything else, and that it is independent of 
the life of the child, being equally appreciable when the uterus con- 
tains a degenerated ovum or dead foetus. The only condition likely 
to give rise to error is an enlargement of the uterus in consequence 
of contents other than the results of conception, such as retained 
menses, or a polypus. The history of such cases — which are more- 
over of extreme rarity — would easily prevent any mistake. As a 
corroborative sign of pregnancy, therefore, I should give these inter- 
mittent contractions a high place. [These intermittent contractions 
are in rare instances accompanied by a sense of pain, and would 

1 Obst. Trans, v. 13. 



SIGNS AXD SYMPTOMS OF PREGNANCY. 141 

appear to threaten miscarriage. We saw one case in which they 
persisted for three weeks, and gradually subdsided under an opiate 
treatment. — Ed.] 

Vaginal Signs of Pregnancy. — The vaginal signs of pregnancy are 
of considerable importance in diagnosis. The)' are chiefly the changes 
which may be detected in the cervix, and the so-called ballottement, 
which depends on the mobility of the foetus in the liquor amnii. 

Softening of the Cervix.- — The alterations in the density and appa- 
rent length of the cervix have been already described (p. 126). When 
pregnancy has advanced beyond the fifth month the peculiar velvety 
softness of the cervix is very characteristic, and affords a strong- 
corroborative sign, but one which it would be unsafe to rely on by 
itself, inasmuch as very similar alterations may be produced by 
various causes. When, however, in a supposed case of pregnancy 
advanced beyond the period indicated, the cervix is found to be 
elongated, dense, and projecting into the vaginal canal, the non- 
existence of pregnancy may be safely inferred. Therefore the nega- 
tive value of this sign is of more importance than the positive. 

Ballottement, when distinctly made out, is a very valuable indica- 
tion of pregnancy. It consists in the displacement, by the examining 
finger, of the foetus, which floats up in the liquor amnii, and falls 
back again on the tip of the finger with a slight tap which is 
exceedingly characteristic. 

Method of Examination. — In order to practise it most easily, the 
patient is placed on a couch or bed in a position midway between 
sitting and lying, by which the vertical diameter of the uterine 
cavity is brought into correspondence with that of the pelvis. Two 
fingers of the right hand are then passed high up into the vagina in 
front of the cervix. The uterus being now steadied from without 
by the left hand, the intravaginal fingers press the uterine wall 
suddenly upwards, when, if pregnancy exist, the foetus is displaced, 
and in a moment falls back again, imparting a distinct impulse to 
the fingers. When easily appreciable it may be considered as a 
certain sign, for although an ante-flexed fundus, or a calculus in the 
bladder, may give rise to somewhat similar sensations, the absence 
of other indications of pregnancy would readily prevent error. Bal- 
lottement is practised between the fourth and seventh months. Be- 
fore the former time the foetus is too small, while at a later period 
it is relatively too large, and can no longer be easily made to rise 
upwards in the surrounding liquor amnii. The absence of ballotte- 
ment must not be taken as proving Hie non-existence <>!' pregnancy, 
for it may be inappreciable from ;i variety of causes, sucn as abnor- 
mal presentations, or the implantation of the placenta upon the 
cervix uteri. 

Vaginal Pulsation. — There are also some other vaginal signs of 
pregnancy of secondary consequence. Amongsl these is the vaginal 
pulsation, pointed oul by Osiander, resulting from the enlargement 
of the vaginal arteries, which may sometimes be Pell beating al an 
early period. Often this pulsation is very distinct, at other time.- it 



142 PREGNANCY. 

cannot be felt at all, and it is altogether unreliable, as a similar pul- 
sation may be felt in various uterine diseases. 

Uterine Fluctuation. — Dr. Kasch lias drawn attention to a previously 
-undescribed sign which, he believes to be of importance in the diag- 
nosis of early pregnancy. 1 It consists in the detection of fluctuation 
through the anterior uterine wall, depending on the presence of the 
liquor amnii. In order to make this out, two fingers of the right 
hand must be used, as in ballottement, while the uterus is steadied 
through the abdomen. Dr. Easch states that by this means the 
enlarged uterus in pregnancy can easily be distinguished from the 
enlargement depending on other causes, and that fluctuation can 
always be felt as early as the second month. If it is associated with 
suppressed menstruation and darkened areolae, he considers it a 
certain sign. In order to detect it, however, considerable experience 
in making vaginal examinations is essential, and it can hardly be 
depended on for general use. 

Alteration in Color of the Vagina. — A peculiar deep violet hue of 
the vaginal mucous membrane was relied on by Jacquemier and 
Kliige as affording a readily-observed indication of pregnancy. In 
most cases it is well marked ; sometimes, indeed, the change of color 
is very intense, and it evidently depends on the congestion produced 
by pressure of the enlarged uterus. The same effect, however, is 
constantly seen where similar pressure is effected by large fibroid 
tumors of the uterus, and, therefore, for diagnostic purposes it is 
valueless. 

Auscultatory Signs of Pregnancy. — By far the most important 
signs are those which can be detected by abdominal auscultation, and 
one of these — the hearing of the foetal heart-sounds — forms the only 
sign which per se, and in the absence of all others, is perfectly reliable. 

Discovery of Foetal Auscultation. — The fact that the sounds of the 
foetal heart are audible during advanced pregnancy was first pointed 
out by Mayor of Geneva in 1818, and the main facts in connection 
with foetal auscultation were subsequently worked out by Kerga- 
radec, Naegele, Evory Kennedy, and other observers. The pulsations 
first become audible, as a rule, in the course of the fifth month, or 
about the middle of the fourth month. In exceptional circumstances, 
and by practised observers, they have been heard earlier. Depaul 
believes that he detected them as early as the eleventh week, and 
Kouth has also detected them at an early period by vaginal stetho- 
scopy, which, however, for obvious reasons, cannot be ordinarily 
employed. Naegele never heard them before the eighteenth week, 
more generally at the end of the twentieth, and for practical purposes 
the pregnancy must be advanced to the fifth month before we can 
reasonably expect to detect them. From this period up to term they 
can almost always be heard, if not at the first attempt, at least after- 
wards, to a certainty, if we have the opportunity of making repeated 
examinations. Accidental circumstances, such as the presence of an 
unusual amount of flatus in the intestines, may deaden the sounds for 

1 Brit. Med. Journ., vol. ii. 1873. 



SIGXS AND SYMPTOMS OF PREGNANCY. 143 

a time, but not permanently. Depaul only failed to hear them in 8 
cases out of 906 examined during the last three months of pregnancy; 
and out of 180 cases, which Dr. Anderson of Glasgow carefully 
examined, he only failed in 12, and in each of these the child was 
still-born. They, therefore, form not only a most certain indication 
of pregnancy, but of the life of the foetus also. 

Description of the Sound. — The sound has been always likened to 
the double tic-tac of a watch heard through a pillow, which it closely 
resembles. It consists of two beats, separated by a short interval, 
the first being the loudest and most distinct, the second being some- 
times inaudible. The rapidity of the foetal pulsations forms an 
important means of distinguishing them from transmitted maternal 
pulsations, with which they might be confounded. Their average 
number is stated by Slater, who made numerous observations on this 
point, to be 132, but sometimes they reach as high as 140, and some- 
times as low as 120. It will thus be seen that the pulsations are 
always much more rapid than those of the mother's heart, unless, 
indeed, the latter be unduly accelerated by transient mental emotion 
or disease. To avoid mistakes, whenever the foetal heart is heard its 
rate of pulsation should be carefully counted, and compared with 
that of the mother's pulse ; if the rates differ, we may be sure that 
no error has been made. The rapidity of the foetal pulsations, re- 
mains, as a rule, the same during the whole period of pregnancy, 
while their intensity gradually increases. They may, however, be 
temporarily increased or diminished in frequency by disturbing- 
causes, such as the pressure of the stethoscope, which, exciting 
tumultuous movements of the foetus, may induce greatly-increased 
frequency of its heart-beats. So also during labor, after the escape 
of the liquor amnii, when the contractions of the uterus have a very 
distinct influence on the foetus, they may be greatly modified An 
acceleration or irregularity of the pulsations, made out in the course 
of a prolonged labor, may thus be of great practical importance, by 
indicating the necessity for prompt interference. Similar alterations, 
associated with tumultuous and unusual foetal movements felt by the 
mother towards the end of pregnancy, may point to danger to the 
life of the foetus during the latter months, and may even justify the 
induction of premature labor. This is especially the case in women 
who have previously given birth to a succession of dead children 
owing to disease of the placenta, and, in them, careful and frequently 
repealed auscultations may warn us of the impending danger. 

Siifi})fis<-f! ilijj'rn'iit'i: <>r' lid/iidiiif according to the Sex of Foetus. — 
The rapidity of the foetal heart has been supposed by some to afford 
a means of determining the sex of the child before birth. Franken- 
hauser, who first directed attention to this point, is of opinion that 
the average rate of pulsations of the heart are considerably less in 
male than in female children, averaging 121 in the minute in the 
former, as against 1 44 in the latter. Stembacfa makes the difference 
somewhat less, viz., 131 for males, and L88 for females, lie pre- 
dicted the sex correctly by this means in 45 out of 57 cases, while 
Frankenhauser was correct in the whole 50 cases which he spe- 



144 PREGNANCY. 

cially examined with reference to the point. Dr. Hntton, of New 
York, 1 was also correct in 7 cases he fixed on for trial. Devilliers 
fonnd the difference in the sexes to be the same as Steinbach ; he 
attributes it, however, to the size and weight, rather than to the sex 
of the child, and believes the pulsations to be least numerous in 
large and well-developed children. As male children are usually 
larger than female, he thus explains the relatively less frequent pul- 
sations of their hearts. Dr. dimming, of Edinburgh, also believes 
that the weight of the child has considerable influeDce on the fre- 
quency of its cardiac pulsations, so that a large female child may 
have a slower pulse than a small male. 2 The point, however, is more 
curious than practical, and the rapidity of the pulsations certainly 
would not justify any positive prediction on the subject. Circum- 
stances influencing the maternal circulation seem to have no influence 
on that of the foetus. 

Site at which the Sounds are heard. — The foetal heart-sounds are 
generally propagated best by the back of the child, and are, there- 
fore, most easily audible when this is in contact with the anterior 
wall of the uterus, as is the case in the large majority of pregnancies. 
When the child is placed in the dorso-posterior position, the sounds 
have to traverse a larger amount of the liquor amnii, and are further 
modified by the interposition of the foetal limbs. They are, there- 
fore, less easily heard in such cases, but even in them they can almost 
always be made out. As the foetus most frequently lies with the 
occiput over the brim of the pelvis, and the back of the child towards 
the left side of the mother, the heart-sounds are usually most dis- 
tinctly audible at a point midway between the umbilicus and the left 
anterior-superior spine of the ilium. In the next most common posi- 
tion, in which the back of the child lies to the right lumbar region of 
the mother, they are generally heard at a corresponding point at the 
right side, but in this case they are frequently more readily made 
out in the right flank, being then transmitted through the thorax of 
the child, which is in contact with the side of the uterus. In breech 
cases, on the other hand, the heart-sounds are generally heard most 
distinctly above the umbilicus, and either to the right or left, accord- 
ing to the side towards which the back of the child is placed. It 
will thus be seen that the place at which the foetal heart-sounds are 
heard varies with the position of the foetus ; and this, when combined 
with the information derived from palpation, affords a ready means 
of ascertaining the presentation of the child before labor. The sounds 
are only audible over a limited space, about two to three inches in 
diameter ; therefore, if we fail to detect them in one place, a careful 
exploration of the whole uterine tumor is necessary before we are 
satisfied that they cannot be heard. 

Sources of Fallacy.— The ou\j mistake that is likely to be made is 
taking the maternal pulsations, transmitted through the uterine 
tumor, for those of the foetal heart. A little care will easily prevent 
this error, and the frequency of the mother's pulse should always be 

2 Edin. Med. Journ., 1875. 



SIGNS AND SYMPTOMS OF PREGNANCY. 145 

ascertained before counting the supposed foetal pulsations. If these 
are found to be 120 or more, while the mother's pulse is only 70 or 
80, no mistake is possible. If the latter is abnormally quickened 
greater care may be necessary, but even then the rate of pulsation of 
each will be dissimilar. Braxton Hicks 1 has pointed out that in 
tedious labor, when the muscular powers of the mother are exhausted, 
the muscular subsurrus may produce a sound closely resembling the 
foetal pulsation ; but error from this source is obviously very im- 
probable. 

Mode of practising Auscultation. — In listening for the foetal heart- 
sounds the patient should be placed on her back, with the shoulders 
elevated and the knees flexed. The surface of the abdomen should 
be uncovered, and an ordinary stethoscope employed, the end of 
which must be pressed firmly on the tumor, so as to depress the ab- 
dominal walls. The most absolute stillness is necessary, as it is often 
far from easy to hear the sounds. Sometimes, after failing with the 
ordinary stethoscope, I have succeeded with the bin-aural, which 
remarkably intensifies them. [Dr. Camman's double instrument 
answers a good purpose. — Ed.] When once heard they are most 
easily counted during a space of five seconds, as, on account of their 
frequency, it is not always possible to follow them over a longer 
period. 

Value of this Sign of Pregnancy. — When the foetal heart-sounds 
are heard distinctly, pregnancy may be absolutely and certainly diag- 
nosed. The fact that we do not hear them does not, however, pre- 
clude the possibility of gestation, for the foetus may be dead, or the 
sounds temporarily inaudible. 

Umbilical Souffle. — There are some other sounds heard in ausculta- 
tion which are of very secondary diagnostic value. One of these is 
the so-called umbilical or funic souffle, which was first pointed out by 
Evory Kennedy. It consists of a single blowing murmur, synchro- 
nous with the foetal heart sounds, and most distinctly heard in the 
immediate vicinity of the point where these are most audible. Most 
authors believe it to be produced by pressure on the cord, cither 
when it is placed between a hard part of the foetus and the uterine 
walls, or is twisted round the child's neck. Schroeder and Hecker 
detected it in fourteen or fifteen per cent, of all cases, and the latter 
believed it to be caused by flexure of the first portion of the cord 
near the umbilicus. For practical purposes it is quite valueless, and 
need only be mentioned as ;i phenomenon which an experienced aus- 
cultator may occasionally detect. 

Uterine Souffle, — The uterine souffle is a peculiar single whizzing 
murmur which is almost always audible on auscultation. Ii varies 
very remarkably in character and position. Sometimes it is a gentle 
blowingor even musical murmur ; al others it is loud, harsh, and scrap- 
ping; sometimes continuous, sometimes intermittent. It may also be 
heard at any point of the uterus, but mosl frequently l<>w down, and to 
one or other side ; more rarely above the umbilicus, or towards the fun- 

1 ( )l)st. Trans., vol. xv. 



146 PREGNANCY. 

dus; and it often changes its position so as to be heard at a subsequent 
auscultation at a point where it was previously inaudible. It may 
be heard over a space of an inch or two only, or, in some cases, over 
the whole uterine tumor; or again, it may sometimes be detected 
simultaneously over two entirely distinct portions of the uterus. It 
is generally to be heard earlier than the foetal heart-sounds, often as 
soon as the uterus rises above the brim of the pelvis, and it can almost 
always be detected after the commencement of the fourth month. 
The sound becomes curiously modified by the uterine contractions 
during labor, becoming louder and more intense before the pain comes 
on, disappearing during its acme, and again being heard as it goes 
off. Hicks attributes to a similar cause, viz., the uterine contractions 
during pregnancy, the frequent variations in the sound which are 
characteristic of it. 1 The uterine souffle is also audible after the 
death of the foetus, and it is believed by some to be modified and to 
become more continuously harsh when that event has taken place. 

Theories as to its Cause. — Very various explanations have been 
given of the causes of this sound. For long it was supposed to be 
formed in the vessels of the placenta, and hence the name " placental 
souffle" by which it is often talked of; or if not in the placenta, in 
the uterine vessels in its immediate neighborhood. The non-placental 
origin of the sound is sufficiently demonstrated by the fact that it 
may be heard for a considerable time after the expulsion of the pla- 
centa. Some have supposed that it is not formed in the uterus at all, 
but in the maternal vessels, especially the aorta and the iliac arteries, 
owing to the pressure to which they are subjected by the gravid 
uterus. The extreme irregularity of the sound, its occasional disap- 
pearance, and its variable site, seem to be conclusive against this 
view. The theory which refers the sound to the uterine vessels is 
that which has received most adherents, and which best meets the 
facts of the case ; but it is by no means easy or even possible to 
account for the exact mode of its production in them. Each of the 
explanations which have been given is open to some objection. It 
is far from unlikely that the intermittent contractions of the uterine 
fibres, which are known to occur during the whole course of preg- 
nancy, may have much to do with it, by modifying, at intervals, the 
rapidity of the circulation in the vessels. Its production in this 
manner may also be favored by the chlorotic state of the blood, to 
which Cazeaux and Scanzoni are inclined to attribute an important 
influence, likening it to the anaemic murmur so frequently heard in the 
vessels in weakly women. 

Diagnostic Value. — From a diagnostic point of view the uterine 
souffle is of very secondary importance, because a similar sound is 
very generally audible in large fibroid tumors of the uterus, and 
even in some few ovarian tumors; it is, therefore, of little or no 
value in assisting us to decide the character of the abdominal enlarge- 
ment. The supposed dependence of the sound on the placental cir- 
culation has caused its site to be often identified with that of the 

1 Op. cit. p. 233. 



SIGNS AND SYMPTOMS OF PREGNANCY. 147 

placenta. It is, however, most frequently heard at the lower part 
of the uterus, while the placenta is generally attached near the 
fundus, so that its position cannot be taken as any safe guide in 
determining the situation of that viscus. 

Sounds produced hy the Movements of the Foetus. — Occasionally, in 
practising auscultation, irregular sounds of brief duration may be 
heard, which are not susceptible of accurate description, and which 
doubtless depend on the sudden movements of the foetus in the 
liquor amnii, or on the impact of its limbs on the uterine walls. 
When heard distinctly t\\Qj are characteristic of pregnancy; and 
they may be sometimes heard when the other sounds cannot be de- 
tected. They are, however, so irregular, and so often entirely absent, 
that they can hardly be looked upon in any other light than as 
occasional phenomena. 

Sounds referred to Decomposition of the Liguor Amnii and to sepa- 
ration of the Placenta. — Two other sounds have been described as 
being sometimes audible, which may be mentioned as matters of 
interest, but which are of no diagnostic value. One is a rustling 
sound, said by Stoltz to be audible in cases in which the foetus is 
dead, and Avhich he refers to gaseous decomposition of the liquor 
amnii; its existence is, however, extremely problematical. The 
other is a sound heard after the birth of the child, and referred by 
Caillant to the separation of the placental adhesions. He describes 
it as a series of rapid short scratching sounds, similar to those pro- 
duced by drawing the nails across the seat of a horse-hair sofa. Simp- 
son 1 admits the existence of the sound, but believed that it is produced 
by the mere physical crushing of the placenta, and artificially imitated 
it out of the body by forcing the placenta through an aperture the 
size of the os uteri. 

Relative Value of the Signs and Symptoms of Pregnancy. — It will 
be seen, then, that although there are numerous signs and symptoms 
accompanying pregnancy, many of them are unreliable by them- 
selves, and apt to mislead. Those which may be confidently de- 
pended on are the pulsations of the foetal heart, which, however, fail 
us in cases of dead children; the foetal movements when distinctly 
made out; ballottement; the intermittent contractions of the uterus; 
and to these we may safely add the presence of milk in the breasts, 
provided we have to do with a first pregnancy. 

The remainder are of importance in leading us to suspect preg- 
nancy, and in corroborating and strengthening other symptoms, but 
they do not, of themselves, justify a positive diagnosis. 

1 Selected Obstet. Works, p. 151. 



148 PREGNANCY. 



CHAPTEE V. 

THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. SPURIOUS PREG- 
NANCY. THE DURATION OF PREGNANCY. SIGNS OF RECENT 
DELIVERY. 

Importance of the Subject. — The differential diagnosis of pregnancy 
has of late years assnmed much importance on account of the advance 
of abdominal surgery. The cases are so numerous in which even 
the most experienced practitioners have fallen into error, and in 
which the abdomen has been laid open in ignorance of the fact that 
pregnancy existed, that the subject becomes one of the greatest con- 
sequence. Fortunately it is less so from an obstetrical than from a 
gynaecological point of view, inasmuch as the converse error, of mis- 
taking some other condition for pregnancy, is of far less consequence, 
as it is one which time will always rectify. But even in this way 
carelessness may lead to very serious injury to the character, if not 
to the health of the patient ; and it will be well to refer briefly to 
some of the conditions most liable to be mistaken for pregnancy, and 
to the mode of distinguishing them. 

Adipose enlargement of the abdomen may obscure the diagnosis by 
preventing the detection of the uterus ; and if, as is not uncommon 
in women of great obesity, it is associated with irregular menstrua- 
tion, the increased size of the abdomen might be supposed to depend 
on pregnancy. The absence of corroborative signs, such as ausculta- 
tory phenomena, mammary changes, and the hardness of the cervix 
as felt per vaginam, make it easy to avoid this error. 

Distension of the uterus by retained menstrual fluid, or watery 
secretion, is an occurrence of rarity that could seldom give rise to 
error. Still it occasionally happens that the uterus becomes enlarged 
in this way, sometimes reaching even to the level of the umbilicus, 
and that the physical character of the tumor is not unlike that of the 
gravid uterus. The best safeguard against mistakes will be the 
previous history of the case, which will always be different from that 
of ordinary pregnancy. Retention of the menses almost always 
occurs from some physical obstruction to the exit of the fluid, such 
as imperforate hymen ; or if it occur in women who have already 
menstruated, we may usually trace a history of some cause, such as 
inflammation following an antecedent labor, which has produced 
occlusion of some part of the genital tract. The existence of a pelvic 
tumor in a girl who has never menstruated will of itself give rise to 
suspicion, as pregnancy under such circumstances is of extreme 
rarity. It will also be found that general symptoms have existed 
for a period of time considerably longer than the supposed duration 
of pregnancy, as judged of by the size of the tumor. The most 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 149 

characteristic of them are periodic attacks of pain due to the addition, 
at each monthly period, to the quantity of retained menstrual fluid. 
Whenever, from any of these reasons, suspicion of the true character 
of the case has arisen, a careful vaginal examination will generally 
clear it up. Tn most cases the obstruction will be in the vagina, and 
is at once detected, the vaginal canal above it, as felt per rectum, 
being greatly distended by fluid ; and we may also find the bulging 
and imperforate hymen protruding through the vulva. The absence 
of mammary changes, and of ballottement, will materially aid us in 
forming a diagnosis. 

Congestive Hypertrophy of the Uterus. — The engorged and enlarged 
uterus, frequently met with in women suffering from uterine disease, 
might readily be mistaken for an early pregnancy, if it happened to 
be associated with amenorrhea. A little time would, of course, soon 
clear up the point, by showing that progressive increase in size, as 
in pregnancy, does not take place. This mistake could only be made 
at an early stage of pregnancy, when a positive diagnosis is never 
possible. The accompanying symptoms — pain, inability to walk, and 
tenderness of the uterus on pressure — would further prevent such an 
error. 

Ascitic Distension of the Abdomen. — Ascites, per se, could hardly be 
mistaken for pregnancy ; for the uniform distension and evident 
fluctuation, the absence of any definite tumor, the site of resonance 
on percussion changing in accordance with alteration of the position 
of the woman, and the unchanged cervix and uterus, should be suffi- 
cient to clear up any doubt, Pregnancy may, however, exist with 
ascites, and this combination may be difficult to detect, and might 
readily be mistaken for ovarian disease, associated with ascites. The 
existence of mammary changes, the presence of the softened cervix, 
ballottement, and auscultation — provided the sounds were not masked 
by the surrounding fluid — would afford the best means of diagnosing 
such a case. 

Uterine and Ovarian Tumors. — One of the most frequent sources 
of difficulty is the differential diagnosis of large abdominal tumors, 
either fibroid or ovarian, or of some enlargements due to malignant 
disease of the peritoneum or abdominal viscera. The most expe- 
rienced have been occasionally deceived under such circumstances. 
As a rule, the presence of menstruation will prevent error, as this 
generally continues in ovarian disease, while in fibroids it is often 
excessive. Tim character of the tumor — the fluctuation in ovarian 
disease, the hard nodular masses in fibroid — and the history of the 
case— especially the length of time the tumor has existed — will aid 
in diagnosis, while the absence of cervical softening, and of auscultatory 
phenomena will further beoi material value in forming a conclusion. 
Some of the mosl difficult cases to diagnose are those in which pr< 
nancy complicates ovarian or fibroid disease. Then the tumor may 
more or less completely obscure the physical signs of pregnancy. 
The usual shape of the abdomen will generally be altered consider- 
ably, and we may be able to distinguish the gravid uterus, separated 
from the ovarian tumor by a distinct sulcus, or with the fibroid 



150 PREGNANCY. 

masses cropping out from its surface. Our chief reliance must then 
be placed in the alteration of the cervix, and in the auscultatory 
signs of pregnancy. 

Spurious Pregnancy. — .The condition most likely to give rise to 
errors is that very interesting and peculiar state, known as spurious 
pregnancy. In this most of the usual phenomena of pregnancy are 
so strangely simulated, that accurate diagnosis is often far from easy. 
There are hardly any of the more apparent symptoms of pregnancy 
which may not be present in marked cases of this kind. The abdo- 
men may become prominent, the areolae altered, menstruation arrested, 
and apparent foetal motions felt ; and, unless suspicion is aroused, and 
a careful physical examination made, both the patient and the prac- 
titioner may easily be deceived. 

Cases in which Spurious Pregnancy occurs. — There is no period of 
the child-bearing life in which spurious pregnancy may not be met 
with ; but it is most likely to occur in elderly women about the 
climacteric period, when it is generally associated with ovarian irrita- 
tion connected with the change of life ; or in younger women, who 
are either very desirous of finding themselves pregnant, or who, being 
unmarried, have subjected themselves to the chance of being so. In 
all cases the mental faculties have much to do with its production, 
and there is generally either very marked hysteria, or even a condi- 
tion closely allied to insanity. Spurious pregnancy is by no means 
confined to the human race. It is well known to occur in many of 
the lower animals. Harvey related instances in bitches, either after 
unsuccessful intercourse, or in connection with their being in heat, 
even when no intercourse had occurred. In such cases the abdomen 
swelled, and milk ajDpeared in the mammae. Similar phenomena are 
also occasionally met with in the cow. In these instances, as in the 
human female, there is probably some morbid irritation of the ova- 
rian system. 

Its Signs and Symptoms. — The physical phenomena are often very 
well marked. The apparent enlargement is sometimes very great, 
and it seems to be produced by a projection forward of the abdomi- 
nal contents due to depression of the diaphragm, together with 
rigidity of the abdominal muscles, and may even closely simulate 
the uterine tumor on palpation. After the climacteric it is frequently 
associated, as Gooch pointed out, with an undue deposit of fat in the 
abdominal walls and omentum, so that there may be even some dul- 
ness on percussion, instead of resonance of the intestines. The foetal 
movements are curiously and exactly simulated, either by involun- 
tary contractions of the abdominal walls, or by the movement of 
flatus in the intestines. The patient also generally fancies that she 
suffers from the usual sympathetic disorders of pregnancy, and thus 
her account of her symptoms will still further tend to mislead. 

Sometimes followed by Spurious Labor. — Not only may the supposed 
pregnancy continue, but, at what would be the natural term of de- 
livery, all the phenomena of labor may supervene. Many authentic 
cases are on record in which regular pains came on, and continued 
to increase in force and frequency until the actual condition was 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 151 

diagnosed. Such mistakes, however, are onlj- likely to happen when 
the statements of the patient have been received without further 
inquiry. "When once an accurate examination has been made, error 
is no longer possible. 

Methods of Diagnosis. — We shall generally find that some of the 
phenomena of pregnancy are absent. Possibly menstruation, more 
or less irregular, may have continued. Examination per vaginam 
will at once clear up the case, by showing that the uterus is not 
enlarged, and that the cervix is unaltered. It may then be very 
difficult to convince the patient or her friends that her symptoms 
have misled her, and for this purpose the inhalation of chloroform is 
of great value. As consciousness is abolished, the semi -voluntary 
projection of the abdominal muscles is prevented, the large apparent 
tumor vanishes, and the bystanders can be readily convinced that 
none exists. As the patient recovers, the tumor again appears. 

Duration of Pregnancy. — The duration of pregnancy in the human 
female has always formed a fruitful theme for discussion amongst 
obstetricians. The reasons which render the point difficult of deci- 
sion are obvious. As the large majority of cases occur in married 
women, in whom intercourse occurs frequently, there is no means of 
knowing the precise period at which conception took place. The 
only datum which exists for the calculation of the probable date of 
delivery is the cessation of menstruation. It is quite possible, how- 
ever, and indeed probable, that conception occurred, in a considerable 
number of instances, not immediately after the last period, but im- 
mediately before the proper epoch for the occurrence of the next. 
Hence, as the interval between the end of one menstruation and the 
commencement of the next averages 25 days, an error to that extent 
is always possible. Another source of fallacy is the fact, which has 
generally been overlooked, that even a single coitus does not fix the 
date of conception, but only that of insemination. It is well known 
that in many of the lower animals the fertilization of the ovule does 
not take place until several days after copulation, the spermatozoa 
remaining in the interval in a state of active vitality within the 
genital tract. It has been shown by Marion Sims that living sper- 
matozoa exist in the cervical canal in the human female some days 
after intercourse. It is very probable, therefore, that in the human 
female, as in the lower animals, a considerable, but unknown interval, 
occurs between insemination and actual impregnation, which may 
render calculations as to the precise duration of pregnancy altogether 
unreliable. 

Average Time between Cessation of Menstruation and Delivery. — A 
large mass of statistical observations exist respecting the average 
duration of gestation, which have been drawn up and collated from 
numerous sources. It would serve no practical purpose to reprinl 
the voluminous tables on this subject that are contained in obstetrical 
works. They arc based on two principal methods of calculation. 
First, we have the length of time between the cessation oi' menstrua- 
tion and delivery. This is found to vary very considerably, bul the 
largest percentage of deliveries occurs between the 271th and 280th 



152 PREGNANCY. 

day after the cessation of menstruation, the average day being the 
278th ; but, in individual instances, very considerable variations both 
above and below these limits are found to exist. Next we have a 
series of cases, from various sources, in which only one coitus was 
believed to have taken place. These are naturally always open to 
some doubt, but, on the whole, they may be taken as affording tole- 
rably fair grounds for calculation. Here, as in the other mode of 
calculation, there are marked variations, the average length of time, 
as estimated from a considerable collection of cases, being 275 days 
after the single intercourse. It may, therefore, be taken as certain 
that there is no definite time which we can calculate on as being the 
proper duration of pregnancy, and, consequently, no method of esti- 
mating the probable date of delivery on which we can absolutely 

rel y- 

Methods of Predicting the probable Date. — The prediction of the 
time at which the confinement may be expected is, however, a point 
of considerable practical importance, and one on which the medical 
attendant is always consulted. Various methods of making the 
calculation have been recommended. It has been customary in this 
country, according to the recommendation of Montgomery, to fix 
upon ten lunar months, or 280 days, as the probable period of gesta- 
tion, and, as conception is supposed to occur shortly after the cessa- 
tion of menstruation, to add this number of days to any day within 
the first week after the last menstrual period as the most probable 
period of delivery. As, however, 278 days is found to be the average 
duration of gestation after the cessation of menstruation, and as this 
method makes the calculation vary from 281 to 287 days, it is evi- 
dently liable to fix too late a date. Naegele's method was to count 
7 days from the first appearance of the last menstrual period, and 
then reckon backwards three months as the probable date. Thus, 
if a patient last commenced to menstruate on August 10, counting in 
this way from August 17 would give May 17 as the probable date of 
the delivery. 

Matthews Duncan has paid more attention than any one else to the 
prediction of the date of delivery. His method of calculating is 
based on the fact of 278 days being the average time between the 
cessation of menstruation and parturition ; and he claims to have had 
a greater average of success in his predictions than on any other plan. 
His rule is as follows : — " Find the day on which the female ceased 
to menstruate, or the first day of being what she calls ■" well." Take 
that day nine months forward as 275, unless February is included, 
in which case it is taken as 273 days. To this add three days in the 
former case, or five if February is in the count, to make up the 278. 
This 278th day should then be fixed on as the middle of the week, 
or, to make the prediction the more accurate, of the fortnight in 
which the confinement is likely to occur, by which mteans allowance 
is made for the average variation of either excess or deficiency." 

Various periodoscopes and tables for facilitating the calculation 
have been made. The periodoscope of Dr. Tyler Smith (sold by 
Messrs. John Smith, 52 Long Acre) is very useful for reference in 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 



153 



the consulting room, giving at a glance a variety of information, 
such as the probable period of quickening, the dates for the induc- 
tion of premature labor, etc. The following table, prepared by Dr. 
Protheroe Smith, is also easily read, and is very serviceable : — 



Table for Calculating the Period of Utero-Gestatiox. 1 





Nine 


Calendar Months. 




Ten Lunar Months. 


From 


To 


Days. 


To 


Days. 


January 


1 


September 30 


273 


October 7 


280 


February 


1 


October 31 


273 


November 7 


280 


March 


1 


November 30 


275 


December 5 


280 


April 


1 


December 31 


275 


January 5 


280 


May 


1 


January 31 


276 


February 4 


280 


June 


1 


February 28 


273 


March 7 


280 


July 


1 


March 31 


274 


April 6 


280 


August 


1 


April 30 


273 


Mav 7 


280 


Septembei 


1 


Mav 31 


273 


June 7 


280 


October 


1 


June 30 


273 


July 7 


280 


November 


1 


July 31 


273 


August 7 


280 


December 


1 


August 31 


274 


September 6 


280 



Quickening a Fallacious Guide in estimating Date of Delivery. — 
The date at which the quickening has been perceived is relied on by 
many practitioners, and still more by patients, in calculating the 
probable date of delivery, as it is generally supposed to occur at the 
middle of pregnancy. The great variations, however, in the time at 
which this phenomenon is first perceived, and the difficulty which is 
so often experienced of ascertaining its presence with any certainty, 
render it a very fallacious guide. The only times at which the per- 
ception of quickening is likely to prove of any real value are when 
impregnation has occurred during lactation (when menstruation is 
normally absent), or when menstruation is so uncertain and irregular 
that the date of its last appearance cannot be ascertained. Asquicken- 
ing is most commonly felt during the fourth month, more frequently 
in its first than in its last fortnight, it may thus afford the only guide 
we can obtain, and that an uncertain one, for predicting the date of 
delivery. 

Is Protraction of Gestation Possible? — From a medico-legal point 
of view the question of the possible protraction of pregnancy beyond 
the average time, and of the limits within which such protraction 
can be admitted, is of very great importance. The law on this point 

1 The above obstetric " Ready Reckoner" consists of two columns, one of calendar, 
the other of lunar months, and may be read a< follows: — A patient has ceased to 
menstruate on July l : her confinement may be expected at Boonest about .March ::i 

{the end of nine calendar months): or at latest <>n April <;. [th< end of ten lunar 
months). Another has ceased to menstruate on January 20 j her confinement may 
be expected on September SO, pins 20 days (the end of nint calendar months) at 

soonest; or on October 7, pins 20 davs (thr end of ten lunar months) at latest. 

11 



154 PREGNANCY. 

varies considerably in different countries. Thus in France it is laid 
down that legitimacy cannot be contested until 300 days have elapsed 
from the death of the husband, or the latest possible opportunity for 
sexual intercourse. This limit is also adopted by Austria, while in 
Prussia it is fixed at 302 days. In England and America no fixed 
date is admitted, but while 280 days is admitted as the "legitimum 
tempus pariendi," each case, in which legitimacy is questioned, is to 
be decided on its own merits. At the early part of the century the 
question was much discussed by the leading obstetricians in connec- 
tion with the celebrated Gardner peerage case, and a considerable 
difference of opinion existed among them. Since that time manj^ 
apparently perfectly reliable cases have been recorded, in which the 
duration of gestation was obviously much beyond the average, and 
in which all sources of fallacy were carefully excluded. 

Reliable Cases of Protraction. — Not to burden these pages with a 
number of cases, it may suffice to refer, as examples of protraction, 
to four well-known instances recorded by Simpson, 1 in which the 
pregnancy extended respectively to 336, 332, 319, and 324 days after 
the cessation of the last menstrual period. In these, as in all cases 
of protracted gestation, there is the possible source of error that im- 
pregnation may have occurred just before the expected advent of the 
next period. Making an allowance of 23 days in each instance for 
this, we even then have a number of days much above the average, 
viz., 313, 309, 296, and 301. Numerous instances as curious may be 
found scattered through obstetric literature. Indeed, the experience 
of most accoucheurs will parallel such cases, which may be more 
common than is generally supposed, inasmuch as they are only likely 
to attract attention when the husband has been separated from the 
wife beyond the average and expected duration of the pregnancy. 

Protraction common in the Lower Animals. — The evidence in favor 
of the possible prolongation of gestation is greatly strengthened by 
what is known to occur in the lower animals. In some of these, as 
in the cow and the mare, the precise period of insemination is known 
to a certainty, as only a single coitus is permitted. Many tables of 
this kind have been constructed, and it has been shown that there is 
in them a very considerable variation. In some cases in the cow it 
has been found that delivery took place 45 days, and in the mare 43 
days after the calculated date. Analogy would go strongly to show, 
that what is known to a certainty to occur in the lower animals, may 
also take place in the human female. The fact, indeed, is now very 
generally admitted ; but we are still unable to fix, with any degree 
of precision, on the extreme limit to which protraction is possible. 
Some practitioners have given cases in which, on data which they 
believe to be satisfactory, pregnancy has been extremely protracted ; 
thus Meigs and Adler record instances which they believed to have 
been prolonged to over a year in one case, and over fourteen months 
in the other. These are, however, so problematical that little weight 
can be attached to them. On the whole it would hardly be safe to 

1 Obstet. Memoirs, p. 84. 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 155 

conclude that pregnancy can go more than three or four weeks 
beyond the average time. This conclusion is justified by the cases 
we possess in which pregnancy followed a single coitus, the longest 
of which was 295 days. 

Evidence from Size of Child. — Dr. Duncan 1 is inclined to refuse 
credence to every case of supposed protraction unless the size and 
weight of the child are above the average, believing that lengthened 
gestation must of necessity cause increased growth of the child. The 
point requires further investigation, and it cannot be taken as proved 
that the foetus necessarily must be large because it has been retained 
longer than usual in utero ; or, even if this be admitted, it may have 
been originally small, and so, at the end of the protracted gestation, 
be little above the average weight. There are, however, many cases 
which certainly prove that a prolonged pregnancy is at least often 
associated with an unusually developed foetus. Dr. Duncan himself 
cites several, and a very interesting one is mentioned by Leishman, 
in which delivery took place 295 days after a single coitus, the child 
weighing 12 lbs. 3 ozs. 

In some Cases Labor may commence and be Arrested. — It seems 
possible that, in some cases of protracted pregnancy, labor actually 
came on at the average time, but, on account of faulty positions of 
the uterus, or other obstructing cause, the pains were ineffective and 
ultimately died away, not recurring for a considerable time. Joulin 
relates some instances of this kind. In one of them the labor was 
expected from the 20th to the 25th of October. He was summoned 
on the 23d, and found the pains regular and active, but ineffective ; 
after lasting the whole of the 21th and 25th they died away, and 
delivery did not take place until November 25th, after the lapse of a 
month. In this instance the apparent cause of difficulty was extreme 
anterior obliquity of the uterus. A precisely similar case came 
under my own observation. The lady ceased to menstruate on 
March 16, 1870. On December 12th, that is on the 273d day, 
strong labor pains came on, the os dilated to the size of a florin, and 
the membranes became tense and prominent with each pain. After 
lasting all night they gradually died away, and did not recur until 
January 12th, 301 days from the cessation of the last period. Here 
there was no assignable cause of obstruction, and the labor, when it 
did come on, was natural and easy. 

The curious fact that, in both these cases, as in others of the same 
kind that are recorded, labor came on exactly a month after the pre- 
vious ineffectual attempt at its establishment, affords, so far as it 
a, an argument in favor of the view maintained by many that 
labor is apt to come OH at what would have been a menstrual period. 

Signs of Recent Delivery. — From a forensic point of view it oft en 
becomes of importance to he able to give a reliable (.pinion as to the 
fact of delivery having occurred, and a few words may he here said 
as to the signs of recenl delivery. Our opinion is only likely to be 
sought in cases in which the Gael of delivery is denied, and in which 

1 Fecundity and Fertility, p. 348. 



356 PREGNANCY. 

we must, therefore, entirely rely on the results of a physical exami- 
nation. If this be undertaken within the first fortnight after labor, 
a positive conclusion can be readily arrived at. 

At this time the abdominal walls will still be found loose and 
flaccid, and bearing very evident marks of extreme distension in the 
cracks and fissures of the cutis vera. These remain permanent for 
the rest of the patient's life, and may be safely assumed to be signs 
of an antecedent pregnancy, provided we can be certain that no other 
cause of extreme abdominal distension has existed, such as ascites, 
or ovarian tumor. 

Within the first few days after delivery, the hard round ball 
formed by the contracted and empty uterus can easily be felt by 
abdominal palpation, and more certainly by combined external and 
internal examination. The process of involution, however, by which 
the uterus is reduced to its normal size, is so rapid, that after the first 
week it can no longer be made out above the brim of the pelvis. In 
cases in which an accurate diagnosis is of importance, the increased 
length of the uterus can be ascertained by the uterine sound, and its 
cavity will measure more than the normal 2 J- inches for at least a 
month after deliver}^. It should not be forgotten that the uterine 
parietes are now undergoing fatty degeneration, and that they are 
more than usually soft and friable, so that the sound should be used 
with great caution, and only when a positive opinion is essential. 
The state of the cervix and of the vagina may afford useful in- 
formation. Immediately after delivery the cervix hangs loose and 
patulous in the vagina, but it rapidly contracts, and the internal os 
is generally entirely closed after the eighth or tenth day. The re- 
mainder of the cervix is longer in returning to its normal shape and 
consistency. It is generally permanently altered after delivery, the 
external os remaining fissured and transverse, instead of circular with 
smooth margins, as in virgins. The vagina is at first lax, swollen, 
and dilated, but these signs rapidly disappear and cannot be satisfac- 
torily made out after the first few days. The absence of the fourchette 
may be recognized, and is a persistent sign. 

The presence of the lochia affords a valuable sign of recent deliv- 
ery. For the first few days they are sanguineous, and contain numer- 
ous blood-corpuscles, epithelial scales, and the ddbris of the decidua. 
After the fifth day they generally change in color, and become pale 
and greenish, and from the eighth or ninth day till about a month 
after delivery, they have the appearance of a thick opalescent mucus. 
They have, however, a peculiar, heavy, sickening odor, which should 
prevent their being mistaken for either menstruation or leucorrhoeal 
discharge. 

The appearance of the breasts will also aid the decision, for it is 
impossible for the patient to conceal the turgid swollen condition of 
the mammae, with the darkened areolae, and, above all, the presence 
of milk. If, on microscopic examination, the milk is found to con- 
tain colostrum corpuscles, the fact of very recent delivery is certain. 
In women who do not nurse it should be remembered that the secre- 
tion of milk often rapidly disappears, so that its absence cannot be 



ABNORMAL PREGNANCY. 157 

taken as a sign that delivery has not taken place. On the whole, 
there should be no difficulty in deciding that a woman has been de- 
livered, as some of the signs are persistent for the rest of her life ; 
but it is not so easy, unless we see the case within the first eight or 
ten days, to say how long it is since labor took place. 



CHAPTER VI. 

ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, SUPER- 



Plural Births an abnormal variety of Pregnancy. — The occurrence 
of more than one foetus in utero is far from uncommon, but there 
are circumstances connected with it which, justify the conclusion that 
plural births must not be classified as natural forms of pregnancy. 
The reasons for this statement have been well collected by Dr. 
Arthur Mitchell, 1 who conclusively shows that not only is there a 
direct increase of risk both to the mother and her offspring, but that 
many abnormalities, such as idiocy, imbecility, and bodily deformity, 
occur with much greater frequency in twins than in single-born 
children. Pie concludes that "the whole history of twin births is 
exceptional, indicates imperfect development and feeble organization 
in the product, and leads us to regard twinning in the human species 
as a departure from the physiological rule, and therofore injurious 
to all concerned." 

Frequency of multiple Births. — The frequency of multiple births 
varies considerably under different circumstances. Taking the aver- 
age of a large number of cases collected by authors in various 
countries, we find that twin pregnancies occur about once in 87 
labors; triplets once in 7679. A certain number of quadruple preg- 
nancies, and some cases of early abortion in which there were five 
foetuses, are recorded, so thai there can be no doubt of the possibility 
of such occurrences; but they arc bo extremely uncommon thai they 
may be looked upon as rare exceptions, the relative frequency of 
which can hardly be determined. 

Ilrhitirn fri'(jvnicy in different Countries. — The frequency of mul- 
tiple pregnancy varies remarkably in differenl races and countries. 
The following table 3 will show this at a glance: — 

1 Med. Times and Gaz., Nov. 1862. 

J Puech, I >'■- Naissances Multiples. 



158 



PREGNANCY. 



Relative Fkequency of Mutiple Pkegnancies in Europe. 



Countries. 


Proportion of 

Twin to Single 

Births. 


Proportion of 
Triplets. 


Proportion of 
Quadruplets. 


E no-land . 


1 : 116 
1 : 94 
1 : 89 
1 : 95 
1 : 99 
1 : 64 
1 : 68.9 
1 : 81.62 
1 : 89 
1 : 50.05 
1 : 79 
1 : 102 
1 : 862 


1 : 6,720 




Austria 








Grand Duchy of Baden 
Scotland . 


1 : 6,575 






France 

Ireland 

Mecklenburg- Scliwerin 

Norway . 

Prussia 

Russia 


1 : 8,256 
1 : 4,995 
1 : 6,436 
1 : 5,442 
1 : 7,820 
1 : 4,054 
1 : 1,000 


1 : 2,074,306 
1 : 167,296 
1 : 183,236 


1 : 394,690 


Saxony . 
Switzerland 


1 : 400,000 


Wurtemberg . 


1 : 6,464 


1 : 110,991 



It will be seen that the largest proportion of multiple births occurs 
in Russia, and that the number of triple births is greatest where twin 
pregnancies are most frequent. Puech concludes that the number of 
multiple pregnancies is in direct proportion to the general fecundity 
of the inhabitants. 

Dr. Duncan has deduced some interesting laws, with regard to the 
production of twins, from a large number of statistical observations; 1 
especially that the tendency to the production of twins increases as 
the age of the woman advances, and is greater in each succeeding 
pregnancy, exception being made for the first pregnancy, in which it 
is greater than in any other. Newly married women appear more 
likely to have twins the older they are. There can be no doubt that 
there is often a strong hereditary tendency in individual families to 
multiple births. A remarkable instance of this kind is recorded by 
Mr. Curgenven, 2 in which a woman had four twin pregnancies, her 
mother and aunt each one, and her grandmother two. Simpson 
mentions a case of quadruplets, consisting of three males and one 
female, who all survived, the female subsequently giving birth to 
triplets. 3 

Sex of Children. — In the largest number of cases of twins the 
children are of opposite sexes, next most frequently there are two 
females, and twin males are the most uncommon. Thus out of 
59,178 labors, Simpson calculates that twin male and female occurred 
once in 199 labors, twin females once in 226, and twin males once in 
258. The proportion of male to female births is also notably less in 
twin than in single pregnancies. 

Size of Foetuses. — Twins, and a fortiori triplets, are almost always 
smaller and less perfectly developed than single children. Hence 



' On Fecundity, Fertility, and Sterility, p. 99. 

2 Obstet. Trans, vol. xi. 3 Obstet. Works, p. 830. 



ABNORMAL PREGNANCY. 159 

the chances of their survival are much less, and Clarke calculates 
the mortality amongst twin children as one out of thirteen. Of 
triplets, indeed, it is comparatively rare that all survive ; while in 
quadruplets, premature labor and the death of the foetuses are almost 
certain. It is a common observation that twins are often unequally 
developed at birth. By some this difference is attributed to one of 
them being of a different age to the other. It is probable, however, 
that in most of these cases the full development of one foetus has been 
interfered with by pressure of the other. This is far from uncom- 
monly carried to the extent of destrojdng one of the twins, which is 
expelled at term, mummified and flattened between the living child 
and the uterine wall. In other cases when one foetus dies it may be 
expelled without terminating the pregnane}^, the other being retained 
in utero and born at term : and those who disbelieve in the possi- 
bility of superfoetation explain in this way the cases in which it is 
believed to have occurred. 

Causes. — Multiple pregnancies depend on various causes. The 
most common is probably the simultaneous, or nearly simultaneous, 
maturation and rupture of two Graafian follicles, the ovules becoming 
impregnated at or about the same time. It by no means necessarily 
follows, even if more than one follicle should rupture at once, that 
both ovules should be impregnated. This is proved by the occur- 
rence of cases in which there are two corpora lutea with only one 
foetus. There are numerous facts to prove that ovules thrown off 
within a short time of each other, may become separately impreg- 
nated, as in cases in which negro women have given birth to twins, 
one of which was pure negro, the other half caste. 

It may happen, however, that a single Graafian follicle contains 
more than one ovule, as has actually been observed before its rup- 
ture ; or, as is not uncommon in the egg of the fowl, an ovule may 
contain a double germ, each of which may give rise to a separate 
foetus. 

Arrangement of the Faital Membranes and Placentse. — The various 
modes in which twins may originate explain satisfactorily the varia- 
tions which are met with in the arrangement of the foetal membrane.-, 
and in the form and connections of the placenta3. In a large pro- 
portion of cases there are two distind bags of membranes, the 
septum between them being composed of four layers, viz., the 
chorion and amnion of each ovum. The placentae are also entirely 
separate. Eere it is obvious thai each twin is developed from a 
distind ovum, having its own chorion and amnion. On arriving in 
the uterus it is probable thai each ovum becomes fixed independently 
in the mucous membrane, and is surrounded by its own decidua 
reflexa. A.s growth advances, the decidua reflexa generally atro- 
phies from pressure, as it is no1 usual to find more than lour layers 
of membrane in the septum separating the ova. In other cases there 

is only «»ne chorion, within which an- two distind amnions, the sep- 
tum then consisting of two layers only. Then the placentse are 
generally in close apposition, and become fused Into a single ma--: 
the cords, separately attached to each foetus, no1 infrequently uniting 



160 PREGNANCY. 

shortly before reaching the placental mass, their vessels anastomosing 
freely. In other more rare instances both foetuses are contained in 
a common amniotic sac ; but, as the amnion is a purely foetal mem- 
brane, it is probable that, when this arrangement is met with, the 
originally existing septum between the amniotic sacs has been 
destroyed. In both these latter cases the twins must have been de- 
veloped from a single ovule containing a double germ, and Schroeder 
states that they are then always of the same sex. Dr. Brunton 1 has 
started a precisely opposite theory, and has tried to prove that twins 
of the same sex are contained in separate bags of membrane, while 
twins of opposite sexes have a common sac. He says that out of 
twenty -five cases coming under his observation, in fifteen the 
children contained in different sacs were of the same sex, but in the 
remaining ten, in which there was only one sac, they were of opposite 
sexes. It is difficult to believe that there is not an error in these 
observations, since twins contained in a single amniotic sac do not 
occur nearly as often as ten times out of twenty-five cases, and no 
distinction is made between a common chorion with two amnions 
and a single chorion and amnion. The facts of double monstrosity 
also disprove this view, since conjoined twins must of necessity arise 
from a single ovule with a double germ, and there is no instance on 
record in which they were of opposite sexes. 

Membranes and Placentae in Triplets. — In triplets the membranes 
and placentae may be all separate, or, as is commonly the case, there is 
one complete bag of membranes, and a second having a common 
chorion, with a double amnion. It is probable, therefore, that trip- 
lets are generally developed from two ovules, one of which contained 
a double germ. 

Diagnosis of Multiple Pregna,ncy . — It is comparatively seldom that 
twin pregnancy can be diagnosed before the birth of the first child, 
and even when suspicion has arisen, its indications are very defective. 
There is generally an unusual size and an irregularity of shape of 
the uterus, sometimes even a distinct depression or suicus between 
the two foetuses. When such a sulcus exists it may be possible to 
make out parts of each foetus b}^ palpation on either side of the 
uterus. The only sign, however, on which the least reliance can be 
placed is the detection of two foetal hearts. If two distinct pulsations 
are heard at different parts of the uterus ; if, on carrying the stetho- 
scope from one point to another, there is an interspace where the 
pulsations are no longer audible, or when they become feeble, and 
again increase in clearness as the second point is reached ; and, above 
all, if we are able to make out a difference in frequency between 
them, the diagnosis is tolerably safe. It must be remembered, how- 
ever, that the sounds of a single heart may be heard over a larger 
space than usual, and hence a possible source of error. Twin preg- 
nancy, moreover, nuvy readily exist without the most careful auscul- 
tation enabling us to detect a double pulsation, especially if one child 
lie in the dorso-posterior position, when the body of the other may 

1 Obst. Trans, vol. x. 



ABNORMAL PREGNANCY. 161 

prevent the transmission of its heart's beat. The so-called placental 
souffle is generally too diffuse and irregular to be of any use in 
diagnosis, even when it is distinctly heard at separate parts of the 
uterus. 

Superfoetation and Superfecundation. — Closely connected with the 
subject of multiple pregnancies are the conditions known as super- 
fecundation and superfoetation, regarding which there has been much 
controversy and difference of opinion. 

By the former is meant the fecundation, at or near the same period 
of time, of two separate ovules before the decidua lining the uterus 
has been formed, which by many is supposed to form an insuperable 
obstacle to subsequent impregnation. The possibility of this occur- 
rence has been incontestably proved by the class of cases already 
referred to, in which the same woman has given birth to twins bear- 
ing evident traces of being the offspring of fathers of different races. 

By superfoetation is meant the impregnation of a second ovule, 
when the uterus already contains an ovum which has arrived at a 
considerable degree of development. The cases which are supposed 
to prove the possibility of this occurrence are very numerous. They 
are those in which a woman is delivered simultaneously of foetuses 
of very different ages, one bearing ail the marks of having arrived 
at term, the other of prematurity ; or of those in which a woman is 
delivered of an apparently mature child, and, after the lapse of a few 
months, of another equally mature. The possibility of superfoetation 
is strongly denied by many practitioners of eminence, and explana- 
tions are given, which doubtless seem to account satisfactorily for a 
large proportion of the supposed examples. In the former class of 
cases it is supposed, with much probability, that there is an ordinary 
twin pregnancy, the development of one foetus being retarded by the 
presence in utero of another. That this is not an uncommon occur- 
rence is certain, and the fact has already been alluded to in treating 
of twin pregnancy. In cases of the latter kind it is possible that 
some of them may be due to separate impregnation in a bilobed 
uterus, the contents of one division being thrown off a considerable 
time before those of the other. Numerous authentic exam] ties of 
tli is occurrence are recorded, but by far the most remarkable is that 
related by Dr. Ross, of Brighton, which has been already referred to 
(p. 58). In this <-asc the patient had previously given birth to many 
children without any suspicion of her abnormal formation having 
arisen, and, had it not been detected by Dr. Ross, the case might 
fairly enough have been claimed as an indubitable example of Buper- 
foetation. 

Making every allowance for these explanations, there remain a 
considerable number of eases which it is very difficult to accounl for, 
except on the supposition that th<- Becond child has been conceived a 
considerable time after the first. Those interested in the subjeel 
will find a large number of examples collected in a valuable paper 
by Dr. Bonnar, of Cupar. 1 lie has adopted the ingenious plan of 

1 Edin. Med. Jour., L864-65. 



162 PREGNANCY. 

consulting the records of the British peerage, where the exact date 
of the birth of successive children of peers is given, without, of 
course, any reasonable possibility of error, and he has collected 
numerous examples of births rapidly succeeding each other, which 
are apparently inexplicable on any other theory. In one case he 
cites, a child was born September 12, 1849, and the mother gave 
birth to another on January 24, 1850, after an interval of only 127 
days. Subtracting from that 14 days, which Dr. Bonnar assumes to 
be the earliest possible period at which a fresh impregnation can 
occur after delivery, we reduce the gestation to 113 days, that is to 
less than four calendar months. As both these children survived, 
the second child could not possibly have been the result of a fresh 
impregnation after the birth of the first; nor could the first child 
have been a twin prematurely delivered, for if so it must have only 
reached rather more than the fifth month, at which time its survival 
would have been impossible. 

Besides the numerous examples of cases of this kind recorded in 
most obstetric works, there are one or two of miscarriage in the 
early months, in which, in addition to a foetus of four or five months' 
growth, a perfectly fresh ovum of not more than a month's develop- 
ment was thrown off. One such case was shown at the Obstetrical 
Society in 1862, which was reported on by Drs. Harley and Tanner, 
who stated that in their opinion it was an example of superfcetation. 
A still more conclusive case is recorded by Tyler Smith. 1 "A young 
married woman, pregnant for the first time, miscarried at the end of 
the fifth month, and some hours afterwards a small clot was dis- 
charged, inclosing a perfectly healthy ovum of about one month. 
There were no signs of a double uterus in this case. The patient had 
menstruated regularly during the time she had been pregnant." This 
case is of special interest from the fact of the patient having men- 
struated during pregnancy — a circumstance only explicable on the 
same anatomical grounds which, render superfcetation possible. So 
far as I know, it is the only instance in which the coincidence of 
superfcetation and menstruation during early pregnancy has been 
observed. 

Objections. — The objections to the possibility of superfcetation are 
based on the assumptions that the decidua so completely fills up the 
uterine cavity that the passage of the spermatozoa is impossible ; 
that their passage is prevented by the mucous plug which blocks up 
the cervix ; and that when impregnation has taken place ovulation 
is suspended. It is, koivever, certain that none of these are insupera- 
ble obstacles to a second impregnation. The first was originally 
based on the older and erroneous view which considered the decidua 
to be an exudation lining the entire uterine cavity, and sealing up 
the mouths of the Fallopian tubes and the aperture of the internal os 
uteri. The decidua reflexa, however, does not come into apposition 
with the decidua vera until about the eighth week of pregnancy, and, 
therefore, until that time there is a free space between the two mem- 

1 Manual of Obstetrics, p. 112. 



ABNORMAL PREGNANCY. 



163 



branes through which the spermatozoa might pass to the open 
mouths of the Fallopian tube, and in which a newly -impregnated 
ovule might graft itself. A reference to the accompanying figure of 
a pregnancy in the third month, copied from Coste's work, will 
readily show that, as far as the decidua is concerned, there is no 
mechanical obstacle to the descent and lodgment of another impreg- 
nated ovule (Fig. 75). Then, as regards the plug of mucus, it is 



Fig. 75. 




Illustrating the Cavity between the Decidua Vera and the Decidua Reflexa during the early 
months of Pregnancy. (After Coste.) 

pretty certain that this is in no way different from the mucus filling 
the cervix in the non-pregnant state, which offers no obstacle at all 
to the passage of the spermatozoa. Lastly, respecting the cessation 
of ovulation during pregnancy, this, no doubt, is the rule, and proba- 
bly satisfactorily explains the rarity of superfcetation. There are, 
however, a sufficient number of authenticated cases of menstruation 
during pregnancy to prove that ovulation is not always absolutely 
in abeyance; and, as long as it occurs, there is unquestionably no 
positive mechanical obstruction, at least in the early months of preg- 
nancy, in the way of the impregnation and lodgment of the ovules 
that are thrown off. The reasonable conclusion, therefore, seems to 
be that, although a large; majority of tin; supposed eases are explica- 
ble in other ways, it cannot be admitted that superfcetation is either 
physiologically or mechanically impossible. 

Extra-uterine Pregnancy. — The mosl importanl of the abnorma] 
varieties of pregnancy, if we consider the serious and very generally 
fatal results attending it, is the so-called extrauterine fcetation, which 
consists in the arrest and development of the ovum outside I be cavity 



164 PREGNANCY. 

of the uterus. Of late years this subject lias received much well- 
merited attention, which, it is to be hoped, may lead to the establish- 
ment of some definite rules for the management of this most anxious 
and dangerous class of cases. 

Site of Extra-uterine Pregnancy. — The ovum may be arrested and 
developed in various situations on its way to the uterus, most com- 
monly in some part of the Fallopian tube, or it may be in the cavity 
of the abdomen, or even quite beyond it, as in a few rare cases in 
which the ovum has found its way into a hernial sac. 

Classification. — Extra-uterine gestation may be subdivided into the 
following classes : 1st, and most common of all, tubal gestation, and 
as varieties of this, although by some made into distinct classes, (a) 
interstitial and (b) tubo- ovarian gestation. In the former of these 
subdivisions the ovum is arrested in the part of the Fallopian tube 
that is situated in the substance of the uterine parietes ; in the latter, 
at or near the fimbriated extremity of the tube — so that part of its 
cyst is formed by the tube and part by the ovary. 2d. Abdominal 
gestation, in which an ovum, instead of finding its way into the tube, 
falls into the peritoneal cavity and there becomes attached and de- 
veloped ; or the so-called secondary abdominal gestation, in which an 
extra-uterine pregnancy, originally tubal, becomes ventral, through 
rupture of its cyst and escape of its contents into the abdominal cavity. 
3d. Ovarian gestation, the existence of which is denied by many 
writers of eminence, such as Velpeau and Arthur Farre, while it is 
maintained by others of equal celebrity, such as Kiwisch, Coste, and 
Hecker. It must be admitted that it is extremely difficult to under- 
stand how an ovarian pregnancy, in the strict sense of the word, can 
occur, for it implies that the ovule has become impregnated before 
the laceration of the Graafian follicle, through the coats of which the 
spermatozoa must have passed. Coste, indeed, believes that this 
frequently occurs ; but, while spermatozoa have been detected on the 
surface of the ovary, their penetration into the Graafian follicle has 
never been demonstrated. Farre has also clearly shown that in many 
cases of supposed ovarian pregnancy the surrounding structures were 
so altered that it was impossible to trace their exact origin, and to 
say, to a certainty, that the foetus was really within the substance of 
the ovary. Kiwisch gives a reasonable explanation of these cases 
by supposing that sometimes the Graafian follicle may rupture, but 
that the ovule may remain within it without being discharged. 
Through the rent in the walls of the follicle the spermatozoa may 
reach and impregnate the ovule, which may develop in the situation 
in which it has been detained. While, therefore, it is impossible, in 
the face of many instances recorded by reliable authorities, to deny 
the existence of ovarian pregnancy, it must be considered to be a 
very rare and exceptional variety, which, as far as treatment and 
results are concerned, does not differ from tubal gestation. 4th. 
There are two rare varieties in which an ovum is developed either 
in the supplementary horn of a bi-lobecl uterus, or in a hernial sac. 

For the sake of clearness, we may place these varieties of extra- 
uterine gestation in the following tabular form : — 



ABNORMAL PREGXAXCY. 1G5 

1st. Tubal— 

(a) Interstitial, (b) Tabo- ovarian. 

2d. Abdominal — 

(a) Primary, (b) Secondary. 

3d. Ovarian. 

4th. In bi-hbed uterus, hernial, etc. 

Causes. — The etiology of extra-uterine fbetation in any individual 
case must necessarily be almost always obscure. Broadly speaking, 
it may be said that extra-uterine foetation may be produced by any 
condition which prevents, or renders difficult, the passage of the 
ovule to the uterus, while it does not prevent the access of the 
spermatozoa to the ovule. Thus inflammatory thickening of the 
coats of the Fallopian tubes by lessening their calibre, but not suffi- 
ciently so to prevent the passage of the spermatozoa, may interfere 
with the movements of the tube which propel the ovum forward, and 
so cause its arrest. A similar effect may be produced by various 
morbid conditions, such as inflammatory adhesions, from old-stand- 
ing peritonitis, pressing on the tube ; obstruction of its calibre by 
inspissated mucus or small polypoid growths ; the pressure of uterine 
or other tumors, and the like. The fact that extra-uterine preg- 
nancies occur most frequently in multiparas, and comparatively rarely 
in women under thirty years of age, tends to show that these con- 
ditions, which are clearly more likely to be met with in such women 
than in young primiparae, have considerable influence in its causation. 
A curiously large proportion of cases occur in women who have 
either been previously altogether sterile, or in whom a long interval 
of time has elapsed since their last pregnancy. The disturbing- 
effects of fright, either during coition or a few days afterwards, have 
been insisted on by many authors as a possible cause. Numerous 
cases of this kind are recorded ; and, although the influence of 
emotion in the production of this condition is not susceptible of proof, 
it is not difficult to imagine that spasms of the Fallopian tubes might 
be produced in this way, which would either interfere with the 
passage of the ovum, or direct it into the abdominal cavity. The oc- 
currence of abdominal pregnancy is probably less difficult to account 
for if we admit, with Coste, that the ovule becomes Impregnated on the 
surface of the ovary itself, for there must be very many conditions 
which prevent the proper adaptation of the fimbriated extremity of 
the tube to the surface of the ovary, and failing this, the ovum must 
of necessity drop into the abdominal cavity. Kiwisch has pointed out 
that this is particularly apl to occur when the Graafian follicle de- 
velops on the posterior surface of the ovary ; and, indeed, it is proba- 
ble that it may be of common occurrence, and thai the comparative 
rarity of abdominal pregnancy is due to the difficulty with which the 
impregnated ovule engrafts itself on the surrounding viscera. Im- 
pregnation may actually occur in the abdominal cavity itself, of which 
Keller 1 relates a remarkable instance. In this ease E£oeberl£had re- 
moved the body of the uterus and pari of the the cervix, leaving the 

1 Dee Grossenes Extra-uterines, Paris, 1872. 



166 



PREGNANCY. 



ovaries. In the portion of the cervix that remained there was a fistu- 
lous aperture opening into the abdominal cavity, through which semen 
passed and produced an abdominal gestation. Several curious cases 
are also recorded, which have given rise to a good deal of discussion, in 
which a tubal pregnancy existed while the corpus luteum was on the 
opposite side (Fig. 76). The most probable explanation, however, is 

Fig. 76. 




Tubal Pregnancy, with the Corpus Luteum in the Ovary of the opposite side. The Decidua is 
represented in the process of detachment from the Uterine Cavity. 

that the fimbriated extremity of the tube in which the ovum was found 
had twisted across the abdominal cavity and grasped the opposite 
ovary, in this way, perhaps, producing a flexion which impeded the 
progress of the ovum it had received into its canal. Tyler Smith 
suggested that such cases might be explained by supposing that the 
ovum, after reaching the uterus, failed to graft itself in the mucous 
membrane, but found its way into the opposite Fallopian tube. 
Kussrnaul 1 thinks that such a passage of the ovum across the uterine 
cavity may be caused by muscular contraction of the uterus, occurring 
shortly after conception, squeezing the yet free ovum upwards 
towards the opening of the opposite tube, and possibly into the tube 
itself. 

The history and progress of cases of extra-uterine pregnancy are 
materially different according to their site, and, for practical pur- 
poses, we may consider them as forming two great classes: the tubal 
(with its varieties), and the abdominal. 

Tubal Pregnancies. — When the ovum is arrested in any part of the 
Fallopian tube the chorion soon commences to develop villi, just as 
in ordinary pregnancy, which engraft themselves into the mucous 
lining of the tube, and fix the ovum in its new position. The 
mucous membrane becomes hypertrophied, much in the same way as 
that of the uterus under similar circumstances; so that it becomes 
developed into a sort of pseudo-decidua. Inasmuch, however, as the 
mucous coat of the tubes is not furnished with tubular glands, a true 
decidua can scarcely be said to exist, nor is there any growth of 

1 Mon. f. Geburt, Oct. 1862. 



ABNORMAL PREGNANCY 



16" 



membrane around the ovum analogous to the decidua reflexa. The 
ovum is, therefore, comparatively speaking, loosely attached to its 
abnormal situation, and hence hemorrhage from laceration of the 
chorion villi can very readily take place. 

It is seldom that any development of the chorion villi into distinct 
placental structure is observed ; this is probably owing to the fact, 
that laceration and death generally occur before the period at which 
the placenta is normally formed. The muscular coat of the tube 
soon becomes hypertrophied, and, as the size of the ovum increases, 
the fibres are separated from each other, so that the ovum protrudes 
at certain points through them, and at these it is only covered by the 
stretched and attenuated mucous and peritoneal coats of the tube. 
At this time the tubal pregnancy forms a smooth oval tumor, which, 
as a rule, has not formed any adhesions to the surrounding structures 



Fig. 




Tulial Pregnancy. (From a Specimen in the Museum of King's College.) 

(Fig. 77). The pari of the tube unoccupied by the ovum may be 
round unaltered, and permeable in both directions; or, more fre- 
quently, it becomes bo Btretched and altered thai its canal cannol be 
detected. Most frequently it is that part of the tube nearest the 
uterus which cannot be made out. The condition of* the uterus in 
this, as in other forms of extra-uterine pregnancy, has been the Bub- 
ject of considerable discussion. It is now universally admitted thai 
the uterus undergoes a certain amounl of sympathetic engorgement, 
the cervix becomes softened, as in natural pregnancy, and the 
mucous membrane develops into a true decidua. In many cases the 
decidua is found on post-mortem examination, in others it is not; 
and hence the doubts that some have expressed as to it.- existence. 



168 PREGNANCY. 

The most reasonable explanation of its absence is that given by 
Duguet, 1 who has shown that it is far from uncommon for the uterine 
decidua to be thrown off en masse during the hemorrhagic dis- 
charges which so frequently precede the fatal issue of extra- uterine 
gestation. 

Interstitial and False Ovarian Pregnancy. — When the ovum is 
arrested in that portion of the tube passing through the uterus, in 
so-called interstitial pregnancy, the muscular fibres of the uterus 
become stretched and distended, and form the outer covering of the 
ovum. When, on the other hand, the site of arrest is in the fimbri- 
ated extremity of the tube, the containing cysts is formed partly of 
the fimbrise of the tube, partly of ovarian tissue ; hence it is much 
more distensible, and the pregnancy may continue without laceration 
to a more advanced period, or even to term, so that when the ovum 
is placed in this situation, the case much more nearly resembles one 
of abdominal pregnancy. 

Period at which Rupture Occurs. — The termination of tubal preg- 
nancy, in the immense majority of cases, is death, produced by lace- 
ration giving rise either to internal hemorrhage, or to subsequent 
intense peritonitis. Eupture usually occurs at an early period of 
pregnancy, most generally from the fourth to the twelfth week, rarely 
later. However, a few instances are recorded in which it did not 
take place until the fourth or fifth month, and Saxtorph and Spiegel- 
berg have recorded apparently authentic cases in which the preg- 
nancy advanced to term without laceration. It is generally effected 
by distension of the tube, which at last yields at the point which is 
most stretched ; and sometimes it seems to be hastened or deter- 
mined by accidental circumstances, such as a blow or fall, or the 
excitement of sexual intercourse. 

Symptoms of Rupture. — The symptoms accompanying rupture are 
those of intense collapse, often associated with severe abdominal 
pain, produced by the laceration of the cyst. The patient will be 
found deadly pale, with a small, thready, and almost imperceptible 
pulse, perhaps vomiting, but with mental faculties clear. If the 
hemorrhage be considerable, she may die without any attempt at re- 
action. Sometimes, however — and this generally occurs in cases in 
which the tube tears, the ovum remaining intact — the hemorrhage 
may cease on account of the ovum protruding through the aperture, 
and acting as a plug. The patient may then imperfectly rally, to be 
again prostrated by a second escape of blood, which proves fatal. 
If the loss of blood is not of itself sufficient to cause death from 
shock and anosmia, the fatal issue is generally only postponed, for the 
effused blood soon sets up a violent general peritonitis, which rapidly 
carries off the patient. If she should survive the second danger, the 
case is transformed into one of abdominal pregnancy, the foetus 
becoming surrounded by a capsule produced by inflammatory exuda- 
tion (Fig. 78). The case is then subject to the rules of treatment 

1 Armales de Gynecologie, May, 1874. 



ABNORMAL PREGNANCY. 169 

presently to be discussed when considering that variety of extra- 

FlG. 78. 



uterine gestation 




Extra-uterine Pregnancy at terra of the Tubo-Ovarian variety. (After a Case of Dr. A. Sibley 

Campbell's.) 

Diagnosis. — The possibility of diagnosing tubal gestation before- 
rupture occurs is a question of great and increasing interest, from the 
fact that, could its existence be ascertained, we might very fairly 
hope to avert the almost certainly fatal issue which is awaiting the 
patient. Unfortunately, the symptoms of tubal pregnancy are always 
obscure, and too often death occurs without the slightest suspicion as 
to the nature of the ease having arisen. In the first place, it is to be 
observed that all the usual sympathetic disturbances of pregnancy 
exist : the breasts enlarge, the areolae darken, and morning Bickness 
is present. There is also an arresl of menstruation; but. after the 
absence of one or more periods, there is often an irregular hemor- 
rhagic discharge. This is an Important Bymptom, this value of 
which in indicating the existence of tubal pregnancy has of late years 
been much dwelt upon by various authors, both iii this country and 
abroad. Barnes attributes it to partial detachment of the chorion 
villi, produced by the ovum growing out of proportion to the tube 
in which it is contained. Whether this is the correcl explanation or 
not, it is a fact that irregular hemorrhage very generally precedes 

12 



170 PKEGNANCY. 

the laceration for several days or more. Accompanying this hemor- 
rhage there is almost always more or less abdominal pain, produced 
by the stretching of the tissues in which the ovum is placed, and this 
is sometimes described as being of a very intense and crampy char- 
acter. If, then, we meet with a case in which the symptoms of early 
pregnancy exist, in which there are irregular losses of blood, possibly 
discharge of membranous shreds, and abdominal pain, a careful ex- 
amination should be insisted on, and then the true nature of the case 
may possibly be ascertained. Should extra-uterine foetation exist, 
we should expect to find the uterus somewhat enlarged, and the cer- 
vix softened, as in early pregnancy, but both these changes are doubt- 
less generally less marked than in normal pregnancy. This fact of 
itself, however, is of little diagnostic value, for slight difference of 
this kind must always be too indefinite to justify a positive opinion. 

Presence of a Peri-uterine Tumor. — The existence of a peri-uterine 
tumor, rounded or oval in outline, and producing more or less dis- 
placement of the uterus, in -the direction opposite to that in which 
the tumor is situated, may point to the existence of tubular foetation. 
By bimanual examination, one hand depressing the abdominal wall, 
while the examining finger of the other acts in concert with it either 
through the vagina or rectum, the size and relations of the growth 
may be made out. There are various conditions, which give rise to 
very similar physical signs, such as small ovarian or fibroid growths, 
or the effusion of blood around the uterus ; and the differential diag- 
nosis must always be very difficult, and often impossible. A curious 
example of the difficulties of diagnosis is recorded by Joulin, in which 
Huguier, and six or seven of the most skilled obstetricians of Paris, 
agreed on the existence of extra-uterine pregnancy, and had, in con- 
sultation, sanctioned an operation, when the case terminated by 
abortion, and proved to be a natural pregnane}^. The use of the 
uterine sound, which might aid in clearing up the case, is necessarily 
contra-indicated unless uterine gestation is certainly disproved. 
Hence it must be admitted that positive diagnosis must almost always 
be very difficult. So that the most Ave can say is, that when the gen- 
eral signs of early pregnancy are present, associated with the other 
symptoms and signs alluded to, the suspicion of tubal pregnancy 
may be sufficiently strong to justify us in taking such action as may 
possibly spare the patient the necessarily fatal consequence of rupture. 

Treatment. — If the diagnosis were quite certain, the removal of 
the entire Fallopian tube and its contents by abdominal section 
would be quite justifiable, and probably would neither be more 
difficult, nor more dangerous, than ovariotomy; for, at this stage of 
extra-uterine foetation, there are no adhesions to complicate the 
operation. As yet, however, the uncertainty of the diagnosis has 
prevented the adoption of the practice. 

[In 1816, Dr. John King, 1 of Edisto Island, South Carolina, ope- 
rated upon a case of extra- uterine pregnancy by the vaginal section, 
and saved both mother and child. The placenta was removed, but 
there does not appear to have been any hemorrhage. — Ed.] 

[ ] New York Med. Repos., 1817, p. 388.] 



ABNORMAL PREGNANCY. 171 

Opening of the Sac by the Galvano-caustic Knife. — Dr. Thomas, of 
New York, 1 has recently recorded a most instructive case, in which 
he saved the life of the patient by a bold and judicious operation. 
The nature of the case was rendered pretty evident by the signs 
above described, and Thomas opened the cyst from the vagina by a 
platinum knife, rendered incandescent by a galvano-caustic battery, 
by which means he hoped to prevent hemorrhage. Through the 
opening thus made he removed the foetus. In subsequently attempt- 
ing to remove the placenta very violent hemorrhage took place, 
which was only arrested by injecting the cyst with a solution of 
persulphate of iron. The remains of the placenta subsequently came 
away piecemeal, after an attack of septicaemia, which was kept 
within bounds by freely -washing out the cyst with antiseptic lotion, 
the patient eventually recovering. If I might venture to make a 
criticism on a case followed by so brilliant a success, it would be that, 
in another instance of this kind, it would be safer to follow the rule 
so strictly laid down with regard to gastrotomy in abdominal preg- 
nancies, and leave the placenta untouched, trusting to the injection of 
antiseptics, and the thorough drainage of the cyst, to prevent mischief. 

[In a second operation, performed on May 10, 1876, in a case of 
secondary abdominal pregnancy, Dr. Thomas 2 operated through the 
linea alba, and removed a female foetus weighing six pounds, fifteen 
ounces. The funis was traced to the left iliac fossa, where it was 
apparently inserted into the peritoneum, and no placenta was dis- 
cernible. The cord was cut off at its origin, and the wound closed, 
except at its lower part, which was kept open by a glass tube. The 
woman's pulse before the operation was 120, and fell to 107 at the 
end of the first week; temperature was always 100° and upwards, 
but in the middle of the fourth week it rose to 103°-101°, and the 
pulse to 130. The placenta was found presenting at the opening in 
the abdomen, and was removed with dressing forceps. It was of the 
ordinary diameter, and had a shrivelled appearance. The removal 
afforded a decided relief, and the temperature fell within three hours. 
Antiseptic injections were freely used in the treatment of the case, 
and the patient made a good recovery. 

The advice given by the author in regard to the non-removal of 
the placenta, was first urged upon the medical profession, so far as 
we can learn, in 1795, in a 3 letter from the late Dr. James Mease, of 
Philadelphia, to Dr. Lettsom, of London, in which he reported an 
operation by Dr. Charles McKnight, of New York, very similar to 
this of Dr. Thomas, and ending favorably to the woman. 4 The 
remarks of Dr. Mease on the impropriety of removing the placenta 
were read before the Medical Society of London, and concurred in 
by some of the members present. 

It is a little remarkable, that the opinion of Dr. Mease originated 

1 New York Med Journ., June. 1875. 
[ 2 Am. Journ. of Obstetrics, vol. ix. p. 655, is:o.] 
f a Memoirs of Med. Soc. London, vol. i, p. 842, I7:i.">.] 

[» More recently I have learned, that Mr. William Trumbull made the Bame re- 
commendation, before the said Society, in 1791.] 



172 PEEGNANCY. 

in an accident which occurred in the operation of Dr. McKnight, by 
which the funis was ruptured, and in consequence of which, the 
placenta, which was outside of the cyst, could not be found for 
removal. The value of this discovery appears to have been lost to 
the profession for a long term of years, as many authors have ob- 
jected to the operation because of the danger of removing the pla- 
centa. — Ed.] 

Means of Destroying the Vitality of the Foetus. — Another mode of 
managing these cases is to destroy the foetus, so as to check its 
further growth, in the hope that it may remain inert and passive 
within its sac. Various operations have been suggested and prac- 
tised for this purpose. Thus needles have been introduced into the 
tumor, through which currents of electricity have been passed, either 
the continuous current, or, as has been suggested hj Duchenne, a 
spark of Franklinic electricity. Hicks, Allen, and others have 
endeavored to destroy the foetus by passing an electro-magnetic 
current through it by means of a needle. In a case reported by Dr. 
Bachetti, in which the continuous current was used, the growth of 
the ovum was arrested, and the patient recovered. The same result, 
however, would probably have followed the simple puncture of the 
cyst. This has been successfully practised on several occasions, 
either with a small trocar and canula, or with a simple needle. A 
very interesting case, in which the development of a two months' 
tubal gestation was arrested in this way, is recorded by Greenhalgh, 1 
and another by Martin, of Berlin. 2 Joulin suggested that not only 
should the cyst be punctured, but that a solution of morphia should 
be injected into it, which, by its toxic influence, would insure the 
destruction of the foetus. Other means proposed for effecting the 
same object, such as pressure, or the administration of toxic remedies 
by the mouth, are far too uncertain to be relied on. The simplest 
and most effectual plan would be to introduce the needle of an 
aspirator, by which the liquor amnii would be drawn off, and the 
further growth of the foetus effectually prevented. Parry, 3 indeed, 
is opposed to this practice, and has collected several cases in which 
the puncture of the cyst was followed by fatal results, either from 
hemorrhage or septicaemia. In these, however, an ordinary trocar 
and canula were probably employed, which would necessarily admit 
air into the sac. It is difficult to imagine that a fine hair-like aspi- 
rating needle, rendered properly antiseptic by carbolic acid, could 
have any injurious results; and it could do no harm, even if an 
error of diagnosis had been made, and the suspected extra-uterine 
foetation turned out to be some other sort of growth. If the aspirator 
proves that an extra-uterine foetation exists, then, if the cyst be of 
any considerable size, and the pregnancy advanced beyond the 
second month, we might, if deemed advisable, resort to a more radi- 
cal operation, such as that so successfully practised by Thomas. 

Treatment when Rupture has Occurred. — When the chance of arrest- 
ing the growth of a tubular foetation has never arisen, and we first 

: Lancet, 1867. 2 Monat. f. Geburt, 1868. 

3 Parry on Extra-Uterine Pregnancy, p. 204. 



ABNORMAL PREGNANCY. 173 

recognize its existence after laceration has occurred, and the patient 
is collapsed from hemorrhage, what course are we to pursue ? Hith- 
erto all that ever has been done is to attempt to rally the patient by 
stimulants, and, in the unlikely event of her surviving the imme- 
diate effects of laceration, endeavoring to control the subsequent 
peritonitis, in the hope that the effused blood may become absorbed, 
as in pelvic hematocele. This is, indeed, a frail reed to rest upon, 
and when laceration of a tubal gestation, advanced beyond a month, 
has occurred, death has been the almost certain result. It is supposed 
by Bernutz, and his opinion is shared by Barnes, that rupture which 
does not prove fatal, is probably not very rare in the first few days 
of extra-uterine gestation, and that it is not an uncommon cause of 
certain forms of pelvic haematocele. It has more than once been sug- 
gested that it would be perfectly justifiable when laceration has oc- 
curred to perform gastrectomy, to sponge away the effused blood, and 
to place a ligature round the lacerated tube and remove it, with its 
contents. This would no doubt be a bold and heroic procedure, but 
no one who is acquainted with the triumphs of modern abdominal 
surgery can say that it would be either impossible or hopeless. The 
sponging out of effused blood from the abdominal cavity is an every- 
day procedure in ovariotomy, nor is there any apparent difficulty in 
ligaturing and removing the sac of the extra-uterine pregnancy, for, 
as a rule, there are no adhesions formed to the surrounding parts. 
The history of these cases shows that death does not generally follow 
rupture for some hours, so that there would be usually time for the 
operation, and the extreme prostration might be, perhaps, tempo- 
rarily counteracted by transfusion. Pressure on the abdominal aorta, 
resorted to when the patient is first seen, might possibly be employed 
with advantage to check further hemorrhage, until the question of 
operation is decided. \Ve must remember that the alternative is 
death and hence any operation which would afford the slightest hope 
of success would be perfectly justifiable. I cannot, therefore, agree 
with those who hold that because the chances of success are so small, 
the operation should not be tried ; and I do not doubt that it will 
y«-t fall to the lot of some one, by this means, to snatch a patient 
from the jaws of death, and still further to extend the successes of 
abdominal surgery. 1 

Abdominal Pregnancy. — In the second of the two classes int.) which, 
for practical convenience, we have divided extra-uterine gestation 
the ovum is developed in the abdominal cavity. It is as yet an open 
question whether in Borne cases the pregnancy is primarily abdominal 
or not. Barnes believes that it probably uever Is so, on accounl of 
the difficulty of admitting that so minute a body as the ovum should 
he able to lix itself on the smooth peritonea] surface. lie therefore 
thinks that all abdominal pregnancies are primarily either tubal or 
ovarian, the sac in which they were contained having given way, 
and the ovum having retained LtS vitality through partial attach- 

[' But for a difference of views in consultation, as t<> diagnosis and treatment, this 

operation would have been performed recently by Dr. I . <i. Thomas, of New 5Tork. 

The patk-nt lived sixty hours. — Ed.] 



174 PREGNANCY. 

ment to the original sac. This theory is opposed to that of the ma- 
jority of writers, and, although it may perhaps render the facts less 
difficult to understand, it is purely hypothetical. There is no evi- 
dence to show that in most cases there is an early laceration of a 
tubal or ovarian sac. That the chorion villi do graft themselves 
upon the surrounding peritoneum is certain, and is observed in all 
cases of abdominal gestation. It is not more difficult to imagine 
them doing this from their very first development than a little later ; 
for it must be allowed that if such laceration does occur, in most 
cases it can only be when pregnancy is very slightly advanced. On 
the whole, therefore it seems not unreasonable to admit the usual 
explanation of these cases, that the ovule, already impregnated, 
escaped the grasp of the Fallopian tube, and fell into the abdominal 
cavity, where it rooted itself and developed. Some have, indeed, 
supposed that abdominal pregnancy may occasionally arise in conse- 
quence of spermatozoa finding their way into the peritoneal cavity, 
and there meeting and impregnating an ovule discharged from the 
Graafian follicle. Such an event one would suppose to be almost im- 
possible, but Koeberle's case, already quoted, proves that it has actu- 
ally occurred. The probability is that it is by no means rare for impreg- 
nated ovules to drop into the peritoneal cavity, and that the majority 
of those that do so perish without doing any harm. When they do 
survive, however, the chorion villi sprout, attach themselves to the 
surrounding structures, and eventually develope into a placenta. 
The mode in which the chorion villi are attached, and the arrange- 
ment of the maternal bloodvessels, have never yet been worked out, 
and would form a very interesting subject for investigation. The 
precise seat of attachment varies, and the placenta has been found 
fixed to most of the abdominal viscera, either those contained in the 
pelvis proper, or it may be the intestines, or to the iliac fossa ; most 
frequently, apparently, the ovum finds its way into the retro-uterine 
cul-de-sac. 

Formation of a Cyst round the Ovum. — The subsequent changes 
vary much. In the large majority of cases the ovum produces con- 
siderable irritation, resulting in the exudation of plastic material, 
which is thrown round it, so as to form a secondary cyst or capsule, 
in which maternal vessels are largely developed, and which stretches, 
pari passu, with the growth of the ovum (Fig. 79). The density and 
strength of this cyst are found to be very different in different cases ; 
sometimes it forms a complete and strong covering to the ovum, at 
others it is very thin and only partially developed, but it is rarely 
entirely absent. As there is ample space for the development of the 
ovum, and as the secondary cyst generally stretches and grows along 
with it, most cases of abdominal pregnancy progress without any 
very remarkable symptoms, beyond occasional severe attacks of pain, 
until the full term of pregnancy has been reached. Sometimes, how- 
ever, the cyst lacerates, and there is an escape of blood into the 
abdominal cavity, accompanied by more or less prostration and col- 
lapse, which may prove fatal, but from Avhich the patient more gen- 
erally rallies. The foetus, now dead, will remain in the abdomen, 



ABNORMAL PREGNANCY. 



175 



and will undergo changes and produce results similar to those which 
we shall presently describe as occurring in cases progressing to the 
full period. 



Fig. 79. 




Uterus and Foetus in a Case of Abdominal Pregnancy. 



Pseudo-labor sometimes comes on. — In most cases at the natural 
termination of pregnancy, a strange series of phenomena occur; 
pseudo-labor comes on, there are more or less frequent and strong- 
uterine contractions, possibly an escape of blood from the vagina, the 
discharge of the broken down uterine decidua, and even the estab- 
lishment of lactation. Sometimes the contractions of the abdominal 
muscles, produced by this ineffective labor, have been so strong as to 
cause the laceration of the adventitious cyst surrounding the foetus, 
and the escape of blood and liquor amnii into the abdominal cavity, 
with a rapidly fatal result. More frequently laceration does not 
occur, and the spurious labor pains continue at intervals, until the 
foetus dies, possibly from pressure, but more often from effusion of 
blood into the tissue of the placenta, and consequent asphyxia. Occa- 
sionally the foetus lias apparently lived a considerable time, in some 
even for several months, after the natural limit of pregnancy 
has been reached. 

Changes after the Death of the Foettts. — It is after the death of the 
foetus that the dangers of abdominal pregnancy generally commence, 
and they are numerous and various. The Bubsequenl changes thai 
oeeui- are well worthy of" study. ( )ccasi< >i 1a 1 ly the foetus has been 
retained for a Length of time, even until the end of a long life, with- 
out producing any serious discomfort, and in many eases of this kind 
several normal pregnancies and deliveries have subsequently taken 
place. Even when the extra -uterine gestation appears to be tolerated, 
and has remained for long without producing any had effects, serious 
symptoms maybe suddenly developed ; so that no woman, under 
such circumstances, can be considered sale. The condition of these 



176 



PREGNANCY 



retained foetuses varies much. Most commonly the liquor amnii is 
absorbed, the foetus shrinks and dies, all its soft structures are changed 
into adipocere, and the bones only remain unaltered. Sometimes 
this change occurs with great rapidity. I have elsewhere 1 recorded 
a case of extra-uterine foetation in which at the full term of pregnancy 
the foetus was alive, and the woman died in less than a year after- 
wards. On post-mortem the foetus was found entirely transformed 
into a greasy mass of adipocere, studded with foetal bones, in which 
not a trace of any of the soft parts could be detected. On the other 
hand the foetus may remain unchanged ; in the Museum of the 
College of Surgeons there is one which was retained in the abdomen 
for fifty -two years, and which was found to be as fresh and unaltered 
as a new-born child. In other cases the sac and its contents atrophy 
and shrink, and calcareous matter is deposited in them, so that the 
whole becomes converted into a solid mass known as a lithopsedion 






Fig. 




(Fig. 80). The cases, however, in which 

gives rise to 



tiie retention of the foetus 
no mischief are quite exceptional. Gene- 
rally the foetus putrefies, and this may 
either immediately cause fatal peritonitis 
or septicaemia ; or, as more commonly 
happens, secondary inflammation and 
suppuration of the sac. Under the in- 
fluence of the latter the sac opens ex- 
ternally, either directly at some point of 
the abdominal walls, or indirectly 
through the vagina, the bowels, or even 
the bladder. Through the aperture or 
apertures thus formed (for there are 
often several fistulous openings), pus, 
and the bones and other parts of the 
broken-down foetus, are discharged ; and 
this may go on for months, and even 
years, until at last, if the patient's 
strength does not give way, the whole 
contents of the cyst are expelled, and 
recovery takes place. From various statistical observations it ap- 
pears, that the chances of recovery are best when the cyst opens 
through the abdominal walls, next through the vagina or bladder, 
and that the foetus is discharged with most difficulty and danger when 
the aperture is formed into the bowel. At the best, however, the 
process is long, tedious, and full of dangers ; and the patient too often 
sinks, during the attempt at expulsion, through the irritation and 
exhaustion produced by the abundant and long-continued discharge. 
Diagnosis. — The diagnosis of abdominal gestation is by no means 
so easy as might be thought, and the most experienced practitioners 
have been mistaken with regard to it. 



Lithopsedion. 

(From a preparation in the Museum of 

the College of Surgeons.) 



The most characteristic symptom, 



although this is not so common 



1 Obst. Trans 



ABNORMAL PREGNANCY. 177 

as in tubal gestation, is metrorrhagia, combined with the general 
signs of pregnancy. Yery severe and frequently repeated attacks 
of abdominal pain are rarely absent, and should at once cause sus- 
picion, especially if associated with hemorrhage. They are supposed 
by some to depend on intercurrent attacks of peritonitis, by which 
the foetal cyst is formed. Parrj^ doubts this explanation, and attrib- 
utes them partly to the distension of the cyst by the growing foetus, 
and partly to pressure on the surrounding structures. On palpation 
the form of the abdomen will be observed to differ from that of nor- 
mal pregnancy, being generally more developed in the transverse 
direction, and the rounded outline of the gravid uterus cannot be 
detected. When development has advanced nearly to term, the ex- 
treme distinctness with which the foetal limbs can be felt will arouse 
suspicion. Per vaginam the os and cervix will be felt softened as in 
ordinary pregnancy, but often displaced by the pressure of the cyst, 
and sometimes fixed by peri-metritic adhesions ; either of these signs 
is of great diagnostic value. 

By bimanual examination it may be possible to make out that the 
uterus is not greatly enlarged, and that it is distinctly separate from 
the bulk of the tumor ; these facts, if recognized, would of them- 
selves disprove the existence of uterine gestation. The diagnosis, if 
the foetal limbs or heart-sounds could be detected, would be cleared 
up in any case by the uterine sound, which would show that the 
uterus was empty and only slightly elongated. But we must be care- 
ful not to resort to this test unless the existence of uterine gestation 
is positively disproved by other means. As, however, it places the 
diagnosis beyond a doubt, it should always be employed whenever 
operative procedure is in contemplation. 

Treatment. — The treatment of abdominal gestation will always be 
a subject of anxious consideration, and there is much difference of 
opinion as to the proper course to pursue. It is pretty generally 
admitted that it is not advisable to adopt any active measures until 
the full term of development is reached. Puncturing the cyst, with 
the view of destroying the foetus and arresting its further growth, 
has been practised, but there are good grounds for rejecting it, for 
there is not the same imminent risk of death from rupture of the 
cyst as in tubal foetation ; and even if the destruction of the foetus 
could be brought about, there would still be formidable dangers from 
subsequent attempts at elimination, or from internal hemorrhage. 

Primary Gastrotomy. — When the full period has arrived, the child 
being still alive, as proved by auscultation, we have to consider 
whether it may not be advisable to perform gastrotomy before the 
foetus perishes, and so at least save the life of the child. There are 
few questions of greater importance, and more difficull to settle. The 
tendency of medical opinion is rather in Favor of immediate opera- 
tion, which is recommended by Velpeau, Kiwisch, Koeberle", Scnroe- 
der, and mnny other writers, whose opinion aecessarily carries greal 
weight. The arguments used in favor of immediate operations are 
that, while it affords a probability of saving the child, the risks bo 
the mother, great though they undoubtedly are, are qoI greaterthan 



178 PREGNANCY. 

those which may be anticipated by delay. If we put off interference 
the cyst may rupture during the ineffectual efforts at labor, and death 
at once ensue ; or, if this does not take place, other risks, which can 
never be foreseen, are always in store for the patient. She may sink 
from peritonitis, or from exhaustion, consequent on the efforts at 
elimination, which in the majority of cases are sooner or later set up, 
so that, as Barnes properly says, " the patient's life may be said to 
be at the mercy of accidents, of which we have no sufficient warn- 
ing." On the other hand, if we delay, while we sacrifice all hope of 
saving the child, we at least give the mother the chance of the foeta- 
tion remaining quiescent for a length of time, as certainly not infre- 
quently occurs. Thus, Campbell collected 62 cases of ultimate re- 
covery after abdominal gestation, in 21 of which the foetus was 
retained without injury for a number of years. Then there is the 
question of secondary gastrotomy, which consists in operating after 
the death of the foetus when urgent symptoms have arisen, a course 
which is advocated by Mr. Hutchinson. In favor of this procedure 
it is urged, that by delay the inflammation taking place about the 
cyst will have greatly increased the chance of adhesions having 
formed between it and the abdominal parietes. so as to shut off its 
contents from the cavity of the peritoneum. The more effectually 
this has been accomplished, the greater are the patient's chances of 
recovery. When the foetus has been dead for some time the vascu- 
larity of the cyst will also be lessened, and the placental circulation 
will have ceased, so that the danger of hemorrhage will be much 
diminished. 

It will be seen, therefore, that there are arguments in favor of 
each of these views. The results of the primary operation are far 
less favorable than we should have, a priori, supposed. Since the 
first edition of this work appeared the subject has been carefully 
studied by Dr. Parry in his exhaustive treatise on Extra-Uterine 
Foetation. He has there shown that when the case is left until 
nature has shown the channel through which elimination is to be 
effected, the mortality is 17.35 less than in the cases in which the 
primary operation was performed. His conclusion is, that " the pri- 
mary operation cannot be too forcibly condemned. It is not too much 
to say that this operation adds only another danger to a life already 
trembling in the balance, which the delusive hope of saving the un- 
certain life of a child does not warrant us in assuming." It is only 
just to remember, as is forcibly pointed out by Keller, that in these 
clays of advanced abdominal surgery a better result might be antici- 
pated than when gastrotomy was performed in the haphazard way 
which was usual before we had gained experience from ovariotomy. 
No doubt minute care in the performance of the operation, a due 
attention to its details, studiously avoiding, as much as possible, the 
passage of blood and the contents of the cyst into the peritoneal 
cavity, would materially lessen its peril. 

Mode of performing the Operation. — The operation, then, should be 
performed with all the precautions with which we surround ovari- 
otomy. The incision, best made in the linea alba, should not be 



ABNORMAL PEEGNANCY. 179 

greater than is necessary to extract the foetus, and may be lengthened 
as occasion requires. If there are no adhesions the walls of the cyst 
should be stitched to the margin of the incision, so as to shut it off 
as completely as possible from the peritoneal cavity. This has been 
specially insisted on by Braxton Hicks, and should never be omitted. 
The special risk is not so much the wounding of the peritoneum, as 
the subsequent entrance of septic matter from the cyst into its cavity. 
Another cardinal rule, both in primary and secondary gastrotomy, 
is to make no attempt to remove the placenta. Its attachments are 
generally so deep-seated and diffused, that any endeavor to separate 
it is likely to be attended with profuse and uncontrollable hemorrhage, 
or with serious injury to the structures to which it is attached. Many 
of the failures after operating can be traced to a neglect of this rule. 
The best subsequent course to pursue, after removing the foetus, and 
arresting all hemorrhage, either by ligature or the actual cautery, is 
to sponge out the cyst as gently as possible, and then to bring the 
upper part of the wound into apposition with sutures, leaving the 
lower open, with the cord protruding, so as to insure an outlet for 
the escape of the placenta as it slips down. The subsequent treat- 
ment must be specially directed to favor the escape of the discharge, 
and to prevent the risk of septicaemia. These objects may be much 
aided by injections of antiseptic fluids, such as a solution of carbolic 
acid, or diluted Condy's fluid ; and it would perhaps be advisable to 
place a drainage tube in the lower angle of the wound. It may be 
well to point 'out that there is no operation in which a scrupulous 
following of the antiseptic method, on Mr. Lister's principles, is so 
likely to be useful. 

Treatment when the Foetus is Dead. — As long as the placenta is re- 
tained the danger is necessarily great, and it may be many days or 
even weeks before it is discharged. When once this is effected the 
sac may be expected to contract, and eventually to close entirely. 

When the foetus is dead, or when we have determined not to attempt 
primary gastrotomy, it is advisable to wait, very carefully watching 
the patient, until either the gravity of her general symptoms, or some 
positive indication of the channel through which nature is about to 
attempt to eliminate the foetus, shows us that the time for action has 
arrived. If there be distinct bulging of the cyst in the vagina, or in 
the petro-vaginal cul-de-sac, especially if an opening has formed there, 
we may properly content ourselves with aiding the passage of the 
foetus through the channel thus indicated, and removing the parts 
that present piecemeal as they come within reach, cautiously enlarg- 
ing the aperture if necessary. If the sac have opened into the intes- 
tines, the expulsion of the foetus through this channel is so tedious 
and difficult, the exhaustion attending it so likely t<> prove fatal, and 
the danger from decomposition of* the foetus through passage of in- 
testinal gas so great, that it would probably he best to attempt to 
remove it by gastrotomy, especially if it is only recently dead, and 
the greater portion is still retained. 

Mode of performing Secondary Gastrotomy. [fan opening forms 
at the abdominal parietes, or if the symptoms determine us to resorl 



180 PREGNANCY. 

to secondary gastrotomy before this occurs, the operation must be 
performed in the same way, and with the same precautions, as primary 
gastrotomy. Here, as before, the safety of the operation must greatly 
depend on the amount and firmness of the adhesions; for if the cyst 
be not completely shut off from the peritoneal cavity, the risks of the 
operation will be little less than those of primary gastrotomy. It 
would obviously materially influence our decision and prognosis if 
we could determine this point before operating. Unfortunately it is 
impossible, as the experience of ovariotomists proves, to ascertain 
the existence of adhesions with any certainty. If, however, we find 
that the abdominal parietes do not move freely over the cyst, and if 
the umbilicus be depressed and immovable, the presumption is that 
considerable adhesions exist. If they are found not to be present, 
the cyst walls should be stitched to the margin of the incision, in the 
manner already indicated, before the contents are removed. 

If the foetus has been long dead, and its tissues greatly altered, its 
removal may be a matter of difficulty. In the case under my own 
care, already alluded to, the foetal structures formed a sticky mass 
of such a nature, that I believe it would have been impossible to 
empty the cyst had an operation been attempted. This possibility 
would be, to some extent, a further argument in favor of the primary 
operation. 

Opening of Cyst by Caustics. — The importance of adhesion has led 
some practitioners to recommend the opening of the cyst by potassa 
fusa or some other caustic, in the hope that it would set up adhesive 
inflammation around the apertures thus formed. Several successful 
operations by this method are recorded, and it would be worth 
trying, should the extreme mobility of the cyst lead us to suspect 
that no adhesions existed. If we have to deal with a case in which 
fistulous openings leading to the cyst have already formed, it may, 
perhaps, be advisable to dilate the apertures already existing, rather 
than make a fresh incision ; but, in determining this point, the sur- 
geon will naturally be guided by the nature of the case, and the 
character and direction of the fistulous openings. 

General Treatment. — It is almost needless to say anything of 
general treatment in these trying cases ; but the administration of 
opiates to allay the sufferings of the patient, and the endeavor to 
support the severely taxed vital energies by appropriate food and 
medication, will form a most important part of the management. 

Gestation in a Bi-lohed Uterus. — A few words may be said as to 
gestation in the rudimentary horn of a bi-lobed uterus, to which 
considerable attention has of late years been directed by the writings 
of Kussmaul and others. It appears certain that many cases of 
supposed tubal gestation are really to be referred to this category. 
Although such cases are of interest pathologically, they scarcety re- 
quire much discussion from a practical point of view, inasmuch as 
their history is pretty nearly identical with that of tubal pregnancy. 
The rudimentary horn is distended by the enlarging ovum, and after 
a time, when further distension is impossible, laceration takes place. 
As a matter of fact, all the 13 cases collected bv Kussmaul termi- 



ABNORMAL PREGNANCY. 181 

nated in this way ; and even on post-mortem examination it is often 
extremely difficult to distinguish them from tubal pregnancies. The 
best way of doing so is probable by observing the relations of the 
round ligaments to the tumor, for, if the gestation be tubal, they will 
be found attached to the uterus on the inner or uterine side of the 
cyst ; whereas, if the pregnancy be in a rudimentary horn of the 
uterus, they will be pushed outwards and be external to the sac. In 
the latter case, moreover, the sac will be probably found to contain 
a true decidua, w r hich is not the case in tubal pregnancy. The only 
point in which they differ is that in cornual pregnancy rupture may 
be delayed to a somewhat later period than in tubal, on account of 
the greater distensibility of the supplementary horn. 

Missed Labor. — The term " missed labor 11 is applied to an exceed- 
ingly rare class of cases in which, at the full period of pregnancy, labor 
has either not come on at all, or, having commenced, the pains have 
subsequently passed off, and the foetus is retained in utero for a very 
considerable length of time. Under such circumstances it has usually 
happened that the membranes have ruptured at or about the proper 
term, and the access of air to the foetus in utero has been followed 
by decomposition. A putrid and offensive discharge has then com- 
menced, and eventually portions of the disintegrating foetus have 
been expelled per vaginam. This discharge may go on until the 
entire foetus is gradually thrown off; or, more frequently, the patient 
dies from septicaemia, or other secondary result of the presence of the 
decomposing mass in utero. 

Thus McClintock relates one case, 1 in which symptoms of labor 
came on in a woman, 45 years of age, at the expected period of de- 
livery, but passed off without the expulsion of the foetus. For a 
period of sixty-seven weeks a highly offensive discharge came away, 
with some few bones, and she eventually died with symptoms of 
pyaemia. He also cites another case in which the patient died in the 
same way, after the foetus had been retained for eleven years. 

Ulceration of the Uterine Walls. — Sometimes, when the foetus lias 
been retained for a length of time, a further source of danger has 
been added by ulceration or destruction of the uterine walls, proba- 
bly in consequent' of an ineffectual attempt at its elimination. This 
occurred in Dr. Oldham's case i Fig. 81), in which the contained mass 
is said to have nearly worn through the anterior wall of the uterus; 
and also in one reported by Sir James Simpson, 2 in which a patient 
died three months after term, i he foel as having undergone (ail v meta- 
morphosis, an opening the size of half-a-erown having formed between 
the transverse colon and the uterine cavity. It is also stated that 
"the uterine walls were as thin as parchment." 

In some few eases, however, probably when the entrance of air 
has been prevented, the foetus has been retained for a length of time 
without decomposing, and without giving rise to any troublesome 
symptoms. Such a case is reported by Dr. Cheston, 8 in which the 
foetus remained in utero for fifty-two years. 

1 Doublin Quart. Journ., Feb. and May, 1864. 

2 Edin. Med. Journ., 1865. ' Med.Chir. Trans., isi \. 



182 PREGNANCY. 

Its Causes. — The causes of this strange occurrence are altogether 
unknown. Generally the foetus seems to have died sometime before 
the proper term for labor, and this may have influenced the character 
of the pains. It is probably also most apt to occur in women of 

Fig. 81. 




Contents of the Cyst in Dr. Oldham's case of Missed Labor. 

feeble and inert habit of body, possibly where there was some obstacle 
to the dilatation of the cervix, which the pains were unable to over- 
come. Barnes suggests 1 that some presumed examples of missed 
labor "were really cases of interstitial gestation, or. gestation in one 
horn of a two-horned uterus." In several of the cases, however, the 
details of the post-mortem examination are too minute to admit of 
the possibility of this mistake having been made. 

From what has been said, it will be seen that the dangers arising 
from this state are very considerable, and when once the full term 
has passed beyond doubt, especially if the presence of an offensive 
discharge shows that decomposition of the foetus has commenced, it 
would be proper practice to empty the uterus as soon as possible, 
The necessary precaution, however, is not to decide too quickly that 
the term has really passed; and, therefore, we must either allow 
sufficient time to elapse to make it quite certain that the case 
really falls under this category, or have unequivocal signs of the 
death of the foetus, and injury to the mother's health. If we had to 
deal with the case before any extensive decomposition of the foetus 

1 Diseases of Women, p. 445. 



DISEASES OF PREGNANCY. 183 

had occurred, we probably should find little difficulty in its manage- 
ment, for the proper course then would be to dilate the cervix with 
the fluid dilators, and remove the foetus by turning; or, before doing 
so, we might endeavor to excite uterine action by pressure and ergot. 
If the case did not come under observation until disintegration of the 
foetus had begun, it would be more difficult to deal with. If the foetus 
had become so much broken up that it was being discharged in pieces, 
Dr. McClintock says that "in regard to treatment, our measures should 
consist mainly of palliatives, viz., rest and hip-baths to subdue uterine 
irritation; vaginal injections to secure cleanliness and prevent ex- 
coriation; occasional digital examination, so as to detect any frag- 
ments of bone that might be presenting at the os, and to assist in 
removing them. These are plain rational measures, and beyond 
them we shall scarcely, perhaps, be justified in venturing. Never- 
theless, under certain circumstances, I would not hesitate to dilate 
the cervical canal so as to permit of examining the interior of the 
womb, and of extracting any fragments of bone that may be easily 
accessible ; but unless they could thus be easily reached and removed, 
the safer course would be to defer, for the present, interfering with 
them. 1 

It may be doubted, I think, whether, considering the serious 
results which are known to have followed so many cases, it would 
not, on the whole, be safer to make at least one decided effort, under 
chloroform, to remove as much as possible of the putrefying uterine 
contents, after the os has been fully dilated. Such a procedure would 
be less irritating than frequently repeated endeavors to pick away 
detached portions of the foetus, as they present at the os uteri. 
"When once the os is dilated, antiseptic intra -uterine injections, as 
of diluted Condy's fluid, might safely and advantageously be used. 
Unquestionably, it would be better practice to interfere and empty 
the uterus as soon as we are quite satisfied of the nature of the case, 
rather than to delay, until the foetus has been disintegrated. 



CIIAPTEK VII. 

DISEASES OF PRECxXAXCY. 

The diseases of pregnancy form a subject so extensive that they 
might well of themselves furnish ample material for a separate 
treatise. The pregnant woman is, of course, liable to the same 
diseases as the non-pregnant; but it is only necessary to allude to 
those whose course and effects are essentially modified by the exist- 

1 Dublin Quart. Journ., vol. xxxvii. p. ,314. 



184. PREGNANCY. 

ence of pregnancy, or which have some peculiar effect on the patient 
in consequence of her condition. There are, moreover, many dis 
orders which can be distinctly traced to the existence of pregnancy. 
Some of them are the direct results of the sympathetic irritations 
which are then so commonly observed; and, of these, several are 
only exaggerations of irritations which may be said to be normal 
accompaniments of gestation. These functional derangements may 
be classed under the head of neuroses, and they are sometimes so 
slight as merely to cause temporary inconvenience, at others so grave 
as seriously to imperil the life of the patient. Another class of 
disorders are to be traced to local causes in connection with the 
gravid uterus, and are either the mechanical results of pressure, or 
of some displacement, or morbid state of the uterus. While the 
origin of others may be said to be complex, being partly due to 
sympathetic irritation, partly to pressure, and partly to obscure 
nutritive changes produced by the pregnant state. 

Derangements of (he Digestive System-. — Among the sympathetic 
derangements there are none which are more common, and none 
which more frequently produce distress, and even danger, than those 
which affect the digestive system. Under the heading of u The Signs 
of Pregnancy," the frequent occurrence of nausea and vomiting has 
already been discussed, and its most probable causes considered (p. 
135). A certain amount of nausea is, indeed, so common an accom- 
paniment of pregnancy, that its consideration as one of the normal 
symptoms of that state is fully justified. We need here only discuss 
those cases in which the nausea is excessive and long-continued, and 
leads to serious results from inanition, and from the constant distress 
it occasions. Fortunately a pregnant woman may bear a surprising 
amount of nausea and sickness without constitutional injury, so that 
apparently almost all aliments may be rejected, without the nutrition 
of the body very materially suffering. At times the vomiting is 
limited to the early part of the day, when all food is rejected, and 
when there is a frequent retching of glairy transparent fluid, in 
severe cases mixed with bile, while at the latter part of the day the 
stomach may be able to retain a sufficient quantity of food, and the 
nausea disappears. In other cases the nausea and vomiting are 
almost incessant. The patient feels constantly sick, and the mere 
taste or sight of food may bring on excessive and painful vomiting. 
The duration of this distressing accompaniment of pregnancy is also 
variable. Generally it commences between the second and third 
months, and disappears after the woman has quickened. Sometimes, 
however, it begins with conception, and continues unabated until 
the pregnancy is over. 

/SymjJtoms of the Graver Cases. — In the worst class of cases, when 
all nourishment is rejected, and when the retching is continuous and 
painful, symptoms of very great gravity, which may even prove 
fatal, develope themselves. The countenance becomes haggard from 
suffering, the tongue dry and coated, the epigastrium tender on pres- 
sure, and a state of extreme nervous irritability, attended with rest- 
lessness and loss of sleep, becomes established. In a still more aggra- 



DISEASES OF PREGNANCY. 185 

vated degree, there is general feverishness, with a rapid, small, and 
thready pulse. Extreme emaciation supervenes, the result of wast- 
ing from lack of nourishment. The breath is intensely fetid, and 
the tongue dry and black. The vomited matters are sometimes 
mixed with blood. The patient becomes profoundly exhausted, a 
low form of delirium ensues, and death may follow if relief is not 
obtained. 

Prognosis. — Symptoms of such gravity are fortunately of extreme 
rarity, but they do from time to time arise, and cause much anxiety. 
Gueniot collected 118 cases of this form of the disease, out of which 
46 died ; and out of the 72 that recovered, in 42 the symptoms only 
ceased when abortion, either spontaneous, or artificially produced, 
had occurred. When pregnancy is over the symptoms occasionally 
cease with marvellous rapidity. The power of retaining and assimi- 
lating food is rapidly regained, and all the threatening symptoms 
disappear. 

Treatment. — In the milder forms of obstinate vomiting, one of the 
first indications will be to remedy any morbid state of the primse 
vise. The bowels will not infrequently be found to be obstinately 
constipated, the tongue loaded, and the breath offensive ; and when 
attention has been paid to the general state of the digestive organs 
by gentle aperient medicines, and antacid remedies, such as bismuth 
and soda, and pepsine after meals, the tendency to vomiting may 
abate without further treatment. 

Regulation of Diet. — The careful regulation of the diet is very im- 
portant. Great benefit is often derived from recommending the 
patient not to rise from the recumbent position in the morning until 
she has taken something. Half a cup of milk and lime-water, or a 
cup of strong coffee, or a little rum and milk, or cocoa and milk, or 
even a morsel of biscuit, taken on waking, often has a remarkable 
effect in diminishing the nausea. When any attempt at swallowing 
solid food brings on vomiting, it is better to give up all pretence at 
keeping to regular meals, and to order such light and easily assimi- 
lated food, at short intervals, as can be retained. Iced milk with 
lime or soda-water, given frequently, and not more than a mouthful 
at a time, will frequently be retained when nothing else will. Cold 
beef jelly, a spoonful at a time, will also be often kept down. Spark- 
ling koumiss lias been strongly recommended as very useful in such 
. and is worthy of trial. It is well, however, to bear in mind, 
in regulating the diet, thai the stomach is fanciful and capricious, 
and that the patienl may l>c able to retain strange and apparently 
unlikely article- of food; and that, if she express a desire for such, 
tic experiment of Letting her have them should certainly be tried. 

.!/. dicinal Treatment.- —The medicines that have been recommended 
are innumerable, and the practitioner will often have to try one after 
the other unsuccessfully ; or may find, in an individual case, thai a 
lemedy will prove valuable which, in another, iiiav be altogether 
powerless. Amongsl those most generally useful arc effervescing 
iraughts, containing from three to five minims of dilute hydrocyanic 
acid; the creasote mixture of the Pharmacopoeia; tincture of mix 
13 



186 PREGNANCY. 

vomica, in doses of five to ten minims ; single minim doses of vinum 
ipecacuanhas, every hour in severe cases, three or four times daily in 
those which are less urgent ; salicine, in doses of three to five grains 
three times a day, recommended by Tyler Smith ; oxalate of cerium, 
in the form of pill, of which three to five grains may be given three 
times a day — a remedy strongly advocated by Sir James Simpson, 
and which occasionally is of undoubted service, but more often fails ; 
the compound pyroxylic spirit of the London Pharmacopoeia in doses 
of rive minims every four hours, with a little compound tincture of 
cardamoms, a drug which is comparatively little known, but which 
occasionally has a very marked and beneficial effect in checking 
vomiting ; opiates in various forms — which sometimes prove useful, 
more often not — may be administered either by the mouth or in pills 
containing from half a grain to a grain of opium, or in small doses 
of the solution of the bimeconate of morphia or of Battley's sedative 
solution, or subcutaneously, a mode of administration which is much 
more often successful. If there is much tenderness about the epigas- 
trium, one or two leeches may be advantageously applied, or one- 
third of a grain of morphia may be sprinkled on the surface of a 
small blister, or cloths saturated in laudanum may be kept over the 
pit of the stomach. In many cases I have found that the applica- 
tion of a spinal ice-bag to the cervical vertebrae, in the manner re- 
commended by Dr. Chapman, has checked the vomiting when all 
drugs have failed. The ice may be placed in one of Chapman's 
spinal ice-bags, and applied for ten minutes or a quarter of an hour, 
twice or three times a day. It invariably produces a comforting 
sensation of warmth, which is always agreeable to the patient. Ice 
may be given to suck ad libitum, and is very useful ; while, if there 
be much exhaustion, small quantities of iced champagne may also 
be given from time to time. 

Local Treatment.— Inasmuch as the vomiting unquestionably has 
its origin, in the uterus, it is only natural that practitioners should 
endeavor to check it by remedies calculated to relieve the irritability 
of that organ. Thus morphia in the form of pessaries per vaginam, 
or belladonna applied to the cervix, has been recommended, and — 
the former especially — are often of undoubted service. A pessary 
containing one-third to half a grain of morphia may be introduced 
night and morning, without interfering with other methods of treat- 
ment. Dr. Hemy Bennet directs especial attention to the cervix, 
which, he says, is almost always congested and inflamed, and covered 
with granular erosions. This condition he recommends to be treated 
by the application of nitrate of silver through the speculum. Dr. 
Clay, of Manchester, corroborates this view, and strongly advocates, 
especially when vomiting continues in the latter months, that one or 
two leeches should be applied to the cervix. Exception may fairly 
be taken to both these methods of treatment as being somewhat 
hazardous, unless other means have been tried and failed. I have 
little doubt, however, that, in many cases, a state of uterine con- 
gestion is an important factor in keeping up the unduly irritable 
condition of the uterine fibres, and an endeavor should always be 



DISEASES OF PREGNANCY. 187 

made to lessen it by insisting on absolute rest in the recumbent pos- 
ture. Of the importance of this precaution in obstinate cases there 
can be no question. Dr. Chapman, of Norwich, strongly recommends 
dilation of the cervix by the finger, and states that he has found it 
very serviceable in checking nausea. It is obvious that this treat- 
ment must be adopted with great caution, as, roughly performed, it 
might lead to the production of abortion. Dr. Hewitt's views as to 
the dependence of sickness on flexions of the uterus have already 
been adverted to, and reasons have been given for doubting the 
general correctness of his theory. It is quite likely, however, that 
well-marked displacements of the uterus, either forwards or back- 
wards, may serve to intensify the irritability of the organ. Cazeaux 
mentions an obstinate case immediately cured by replacing a retro- 
verted uterus. A careful vaginal examination should, therefore, be 
instituted in all intractable cases, and if distinct displacement be de- 
tected, an endeavor should be made to support the uterus in its 
normal axis. If retroverted, a Hodge's pessary may be safely em- 
ployed ; if anteverted, a small air-ball pessary, as recommended by 
Hewitt, should be inserted. I believe, however, that such displace- 
ments are the exception rather than the rule in cases of severe 
sickness. 

The importance of promoting nutrition by every means in our 
power should always be borne in mind. The exhaustion produced 
by want of food soon increases the irritable state of the nervous 
system, and, if the stomach will not retain anything, we can only 
combat it by occasional nutrient enemata of strong beef tea, yolk of 
egg, and the like. 

The Production of Artificial Abortion. — Finally, in the worst class 
of cases, when all treatment has failed, and when the patient has 
fallen into the condition of extreme prostration already described, we 
may be driven to consider the necessity of producing abortion. For- 
tunately cases justifying this extreme resource are of great rarity, 
but nevertheless there is abundant evidence that, every now and then, 
women do die from uncontrollable vomiting, whose lives might have 
been saved had the pregnancy been brought to an end. The value 
of artificial abortion has been abundantly proved. Indeed, it is re- 
markable how rapidly the serious symptoms disappear when the 
uterus is emptied, and the tension of the uterine fibres lessened. It 
has fortunately but rarely fallen to my lot to have to perforin this 
operation for intractable vomiting. In one such case tin-, patient was 
reduced t<>a state of the utmost prostration, having kept hardly any 
food on her stomach for many weeks, and when I first saw her she 
was lying in a state of l'»w muttering delirium. Within a lew hours 
after abortion was Induced all the threatening symptoms had disap- 
peared, the vomiting had entirely ceased, and she was next day able 
to retain and absorb all that was given to her. The value of the 
operation, therefore, I believe to be undoubted. Where it has failed, 
it seems to have been on account of undue delay. Owing to the 
natural repugnance which all must feel towards this plan, it has gene- 
rally been postponed until the patient has been too exhausted to rally. 



188 PREGNANCY. 

If, therefore, it is done at all, it should be before prostration has ad- 
vanced so far as to render the operation useless. In these cases the 
obvious indication is to lessen the tension of the uterus at once, and 
therefore the membranes should be punctured by the uterine sound, 
so as to let the liquor amnii drain away, and this may of itself be 
sufficient to accomplish the desired effect. It is almost needless to 
add, that no one would be justified in resorting to this expedient 
without having his opinion fortified by consultation with a fellow- 
practitioner. 

Other disorders of the digestive system may give rise to considerable 
discomfort, but not to the serious peril attending obstinate vomiting. 
Amongst them are loss of appetite, acidity and heartburn, flatulent 
distension, and sometimes a capricious appetite, which assumes the 
form of longing for strange and even disgusting articles of diet. As- 
sociated with these conditions there is generally derangement of the 
whole intestinal tract, indicated by furred tongue and sluggish bowels, 
and they are best treated by remedies calculated to restore a healthy 
condition of the digestive organs, such as a light easily digested diet, 
mineral acids, vegetable bitters, occasional aperients, bismuth and 
soda, and pepsine. The indications for treatment are not different 
from those which accompany the same symptoms in the non-pregnant 
state. 

Diarrhoea is an occasional accompaniment of pregnancy, often de- 
pending on errors of diet. When excessive and continuous it has a 
decided tendency to induce uterine contractions, and I have frequently 
observed premature labor to follow a sharp attack of diarrhoea. It 
should, therefore, not be neglected ; and, if at all excessive, should 
be checked by the usual means, such as chalk mixture with aromatic 
confection, and small doses of laudanum or chlorodyne. The possi- 
bility of apparent diarrhoea being associated with actual constipation, 
the fluid matter finding its way past the solid materials blocking up 
the intestines, should be borne in mind. 

Constipation is much more common, and is indeed a very general 
accompaniment of pregnancy, even in women who do not suffer from 
it at other times. It partly depends on the mechanical interference 
of the gravid uterus with the proper movements of the intestines, 
and partly on defective innervation of the bowels resulting from the 
altered state of the blood. The first indication will be to remedy 
this defect by appropriate diet, such as fresh fruits, brown bread, oat- 
meal porridge, etc. Some medicinal treatment will also be necessary, 
and, in selecting the drugs to be used, care should be taken to choose 
such as are mild and unirritating in their action, and tend to improve 
the tone of the muscular coats of the intestine. A small quantity 
of aperient mineral water in the early morning, such as the Hunyadi, 
Freclerickshalle, or Pullna water, often answers very well ; or an oc- 
casional dose of the confection of sulphur; or a pill containing three 
or four grains of the extract of colocynth, with a quarter of a grain 
of the extract of nux vomica, and a grain of extract of hyoscyamus 
at bed time ; or a teaspoonful of the compound liquorice powder in 
milk at bed time. Constipation is also sometimes effectually combated 



DISEASES OF PREGNANCY. 189 

by administering, twice daily, a pill containing a couple of grains of 
the inspissated ox-gall, with a quarter of a grain of extract of bella- 
donna. Enemata of soap and water are often very useful, and have 
the advantage of not disturbing the digestion. In the latter months 
of pregnancy, especially in the few weeks preceding delivery, the 
irritation produced by the collection of hardened feces in the bowel 
is a not infrequent cause of the annoying false pains which then so 
commonly trouble the patient. In order to relieve them, it will be 
necessary to empty the bowels thoroughly by an aperient, such as a 
good dose of castor-oil, to which fifteen or twenty minims of laudanum 
may be advantageously added. Should the rectum become loaded 
with scybalous masses, it may be necessary to break clown and re- 
move them by mechanical means, provided we are unable to effect 
this by copious enemata. 

Hemorrhoids. — The loaded state of the rectum so common in preg- 
nancy, combined with the mechanical effect of the pressure of the 
gravid uterus on the hemorrhoidal veins, often produces very trou- 
blesome symptoms from piles. In such cases a regular and gentle 
evacuation of the bowels should be secured daily, so as to lessen as 
much as possible the congestion of the veins. Any of the aperients 
already mentioned, especially the sulphur electuary, may be used. 
Dr. Fordj^ce Barker 1 insists that, contrary to the usual impression, 
one of the best remedies for this purpose is a pill containing a grain 
or a grain and a half of powdered aloes, with a quarter of a grain of 
extract of nux vomica, and that castor oil is distinctly prejudicial, 
and apt to increase the symptoms. I have certainly found it answer 
well in several cases. When the piles are tender and swollen, they 
should be freely covered with an ointment consisting of four grains 
of muriate of morphia to an ounce of simple ointment, or with the 
Ung. Gallae c. opio [an addition of 5j of ext. of stramonium to 3j of 
this ointment, will be found valuable. — Ed.] of the Pharmacopoeia; 
and, if protruded, an attempt should be made to push them gently 
above the sphincter, by which they are often unduly constricted. 
Eelief may also be obtained by frequent hot fomentations, and some- 
times, when the piles are much swollen, it will be found useful to 
puncture them, so as to lessen the congestion, before any attempt at 
reduction is made. 

Ptyalisrn. — A profuse discharge from the salivary glands is an 
occasional distressing accompaniment of pregnancy. It is generally 
confined to the early months, but it occasionally continues during the 
whole period of gestation, and resists all treatment, only ceasing 
when delivery is over. Under such circumstances the discharge of 
saliva is sometimes enormous, amounting to several quarts a day, 
and the distress and annoyance to the patient are very great. In one 
case under my care the saliva pomed Prom the mouth all day long, 
and for several months the patient sal with a basin constantly by her 
side, incessantly emptying her mouth, until she was reduced to a 
condition giving rise to really serious anxiety. This profuse saliva- 

1 The Puerperal Diseases, p 33. 



190 PREGNANCY. 

tion is, no doubt, a purely nervous disorder, and not readily con- 
trolled by remedies. Astringent gargles, containing tannin and 
chlorate of potass, frequent sucking of ice, or of tannin lozenges, in- 
halation of turpentine and creasote, counter-irritation over the sali- 
vary glands by blisters or iodine, the bromides, opium internally, 
may all be tried in turn, but none of them can be depended on with 
any degree of confidence. 

Toothache and Caries of the Teeth. — Severe dental neuralgia is also 
a frequent accompaniment of pregnancy, especially in the early 
months. When purely neuralgic, quinine in tolerably large doses is 
the best remedy at our disposal ; but not infrequently, it depends on 
actual caries of the teeth, and attention should always be paid to the 
condition of the teeth when facial neuralgia exists. There is no 
doubt that pregnancy predisposes to caries, and the observation of 
this fact has given rise to the old proverb, " for every child a tooth." 
Mr. Oakley Coles, in an interesting paper 1 on the condition of the 
mouth and teeth during pregnancy, refers the prevalence of caries to 
the co-existence of acid dyspepsia, causing acidity of the oral secre- 
tions. There is much unreasonable dread amongst practitioners as 
to interfering with the teeth during pregnancy, and some recommend 
that all operations, even stopping, should be postponed until after 
delivery. It seems to me certain that the suffering of severe tooth- 
ache is likely to give rise to far more severe irritation than the opera- 
tion required for its relief, and I have frequently seen badly decayed 
teeth extracted during pregnancy, and with only a beneficial result. 
[We have had nitrous oxide administered and teeth extracted with- 
out difficulty, or any apparent risk. — Ed.] 

Affections of the Respiratory Organs. — Amongst the derangements 
of the respiratory organs, one of the most common is spasmodic 
cough, which is often excessively troublesome. Like many other of 
the sympathetic derangements accompanying gestation, it is purely 
nervous in character, and is unaccompanied by elevated temperature, 
quickened pulse, or any distinct auscultatory phenomena. In char- 
acter it is not unlike whooping-cough. The treatment must obviously 
be guided by the character of the cough. Expectorants are not likely 
to be of service, while benefit may be derived from some of the anti- 
spasmodic class of drugs, such as belladonna, hydrocyanic acid, opi- 
ates, or bromide of potassium. Such remedies may be tried in suc- 
cession, but will often be found to be of little value in arresting the 
cough. Dyspnoea may also be nervous in character, and sometimes 
symptoms, not unlike those of spasmodic asthma, are produced. 
Like the other sympathetic disorders, it, as well as nervous cough, 
is most frequently observed during the early months. There is an- 
other form of dyspnoea, not uncommonly met with, which is the me- 
chanical result of the interference with the action of the diaphragm 
and lungs by the pressure of the enlarged uterus. Hence this is 
most generally troublesome in the latter months, and continues unre- 
lieved until delivery, or until the sinking of the uterine tumor which 

1 Trans, of the Odontologieal Society. 



DISEASES OF PREGNANCY. 191 

immediately precedes it. Beyond taking care that the pressure is 
not increased by tight lacing, or injudicious arrangement of the 
clothes, there is little that can be done to relieve this form of breath- 
lessness. [Anoint the abdomen of the patient, and let her sleep on 
an inclined plane with a pillow under her thighs and knees. — Ed.] 

Palpitation, like dyspnoea, may be due either to sympathetic dis- 
turbance, or to mechanical interference with, the proper action of the 
heart. When occurring in weakly women it may be referred to the 
functional derangements which accompany the chlorotic condition 
of the blood often associated with pregnancy, and is then best reme- 
died by a general tonic regimen, and the administration of ferruginous 
preparations. At other times anti-spasmodic remedies may be indi- 
cated, but it is seldom sufficiently serious to call for much special 
treatment. 

Syncope. — Attacks of fainting are not rare, especially in delicate 
women of highly -developed nervous temperament, and are perhaps 
most common at or about the period of quickening, although some- 
times lasting through the whole pregnancy. In most cases these 
attacks cannot be classed as cardiac, but are more probably nervous 
in character, and they are rarely associated with complete abolition 
of consciousness. They rather, therefore, resemble the condition 
described by the older authors as lypothemia. The patient lies in a 
semi-unconscious condition with a feeble pulse and widely-dilated 
pupils, and this state lasts for varying periods, from a few minutes 
to half an hour or more. In one very troublesome case under my 
care they often recurred as frequently as three or four times a day. 
I have observed that they rarely occur when the more common sym- 
pathetic phenomena of pregnancy, especially vomiting, are present. 
Sometimes they terminate with the ordinary symptoms of hysteria 
such as sobbing. The treatment should consist during the attack in 
the administration of diffusible stimulants, such as ether, sal- volatile, 
and valerian, the patient being placed in the recumbent position with 
the head low. If frequently repeated it is unadvisable to attempt to 
rally the patient by the too free administration of stimulants. In the 
intervals a generally tonic regimen, and the administration of ferru- 
ginous remedies, are indicated. If they recur with great frequency 
the daily application of the spinal ice-bag has proved of much service. 

Extreme Anoemia and Chlorosis. — In connection with disorders of 
the circulatory system may be noticed those which depend on the 
state of the blood. The altered condition of the blood, which lias 
already been described as a physiological accompaniment of pregnancy 
(p. 130), is sometimes carried to an extent which may fairly be called 
morbid ; and, either on account of the deficiency of blood-corpnseles, 
or from the increase in its watery constituents, a state of extreme 

anaemia and chlorosis maybe developed. This maybe b etimes 

carried to a very serious extent. Thus Gusserow 1 records five cases 
in which nothing but excessive anaemia could be detected, all of which 
ended fatally. Generally when such symptoms have been carried to 

1 Arch. f. Gyn. ii. 2, 1*71. 



192 PREGNANCY. 

an extreme extent, the patient has been in a state of chlorosis before 
pregnancy. The treatment must, of course, be calculated to improve 
the general nutrition, and enrich the impoverished blood ; a light 
and easily assimilated diet, milk, eggs, beef-tea, and animal food — if 
it can be taken — attention to the proper action of the bowels, a due 
amount of stimulants, and abundance of fresh air, will be the chief 
indications in the general management of the case. Medicinally, fer- 
ruginous preparations will be required. Some practitioners object, 
apparently without sufficient reason, to the administration of iron 
during pregnancy, as liable to promote abortion. This unfounded 
prejudice may probably be traced to the supposed emmenagogue prop- 
erties of the preparations of iron ; but, if the general condition of the 
patient indicate such medication, they may be administered without 
any fear Preparations of phosphorous, such as the phosphide of 
zinc, or free phosphorous in capsules, also promise favorably, and 
are well worthy of trial. 

(Edema associated with Hydrsemia. — Some of the more aggravated 
cases are associated with a considerable amount of serous effusion 
into the cellular tissue, generally limited to the lower extremities, 
but occasionally extending to the arms, face, and neck, and even 
producing ascites and pleuritic effusion. Under the latter circum- 
stances this complication is, of course, of great gravity, and it is said 
that after delivery the disappearance of the serous effusion may be 
accompanied by metastasis of a fatal character to the lungs or the 
nervous centres. This form of oedema must be distinguished from 
the slight oedematous swelling of the feet and legs so commonly ob- 
served as a mechanical result of the pressure of the gravid uterus, 
and also from those cases of oedema associated with albuminuria. 
The treatment must be directed to the cause, while the disappearance 
of the effusion may be promoted by the administration of diuretic 
drinks, the occasional use of saline aperients, and rest in the horizon- 
tal position. 

Albuminuria. — The existence of albumen in the urine of pregnant 
women has for many years attracted the attention of obstetricians, 
and it is now well known to be associated, in ways still imperfectly 
understood, with many important puerperal diseases. Its presence 
in most cases of puerperal eclampsia was long ago pointed out by 
Lever in this country and Rayer in France, and its association with 
this disease gave rise to the theory of the dependence of the convul- 
sion on uraemia, which is still generally entertained. It has been 
shown of late years, especially by Braxton Hicks, that this associa- 
tion is by no means so universal as was supposed ; or rather that, in 
some cases, the albuminuria follows and does not precede the convul- 
sions, of which it might therefore be supposed to be the consequence 
rather than the cause ; so that further investigations as to these par- 
ticular points are still required. Modern researches have shown that 
there is an intimate connection between many other affections and 
albuminuria ; as, for example, certain forms of paralysis, either of 
special nerves, as puerperal amaurosis, or of the spinal system ; 
cephalalgia and dizziness ; puerperal mania ; and possibly hemor- 



DISEASES OF PREGNANCY. 193 

rhage. It cannot, therefore, be doubted that albuminuria in the 
pregnant woman is liable, at any rate, to be associated with grave 
disease, although the present state of our knowledge does not enable 
us to define very distinctly its precise mode of action. 

Causes of Puerperal Albuminuria. — As the presence of albumen 
in the urine of pregnant women is far from a rare phenomenon — 
being met with, according to the researches of Blot and Litzman, in 
20 per cent, of pregnant women — and as, in the large majority of 
these cases, it rapidly disappears after delivery, it is obvious that its 
presence must, in a large proportion of cases, depend on temporary 
causes, and has not always the same serious importance as in the 
non-pregnant state. This is further proved by the undoubted fact 
that albumen, rapidly disappearing after delivery, is often found in 
urine of pregnant women who go to term, and pass through labor 
without any unfavorable symptoms. 

Pressure by the Gravid Uterus. — The obvious fact that in pregnancy 
the vessels supplying the kidneys are subjected to mechanical pres- 
sure from the gravid uterus, and that congestion of the venous circu- 
lation of those viscera must necessarily exist to a greater or less 
degree, suggests that here we may find an explanation of the frequent 
occurrence of albuminuria. This view is further strengthened by the 
fact that the albumen rarely appears until after the fifth month, and, 
therefore, not until the uterus has attained a considerable size; and 
also that it is comparatively more frequently met with in primiparae, 
in whom the resistance of the abdominal parietes, and consequent 
pressure, must be greater than in women who have already borne 
children. It is, indeed, probable that pressure and consequent venous 
congestion of the kidneys have an important influence in its produc- 
tion; but there must be, as a rule, some other factor in operation, 
since an equal or even greater amount of pressure is often exerted 
by ovarian and fibroid tumors, without any such consequences. 

Altered State of the Blood. — This is probably to be found in the 
altered condition of the blood, which, on account of the unusual call 
for nutritive supply on the part of the foetus, contains an excess of 
albuminous material. Hence we have two factors always at work in 
the pregnant woman, both predisposing to the escape of albumen, 
viz., a turgid state of the renal venous system, and a super-albumi- 
nous condition of the blood. But in the large majority of cases, 
although these conditions are present, no albuminuria exists, and they 
must, therefore, be looked upon as predisposing causes, to which some 
other is added before the albumen escapes from the vessels. What 
this is generally escapes our observation, but probably any condition 
producing sudden hyperemia of the kidneys, and giving rise to a 
state analogous to the firsi stage of Bright's disease — such, for ex- 
ample, as sudden exposure to cold and Impeded cutaneous action — 
may be sumcienl to set a lighl to the match already prepared by the 
existence of pregnancy. In addition to these temporary causes it 
must not be forgotten that pregnancy may supervene in a patient 
already sutVering from Blight's disease, when of course the albumen 
will exist in the urine from the com met ment of gestation. 



194 PREGNANCY. 

The Effects of Puerperal Albuminuria. — The various diseases asso- 
ciated with the presence of albumen in the urine will require sepa- 
rate consideration. Some of these, especially puerperal eclampsia, are 
amongst the most dangerous complications of pregnancy. Others, such 
as paralysis, cephalalgia, dizziness, may also be of considerable gravity. 
The precise mode of their production, and whether they can be traced, 
as is generally believed, to the retention of urinary elements in the 
blood, either urea or free carbonate of ammonia produced by its de- 
composition, or whether the two are only common results of some 
undetermined cause, will be considered when we come to discuss 
puerperal convulsions. Whatever view may ultimately be taken on 
these points, it is sufficiently obvious that albuminuria in a pregnant 
woman must constantly be a source of much anxiety, and must induce 
us to look forward with considerable apprehension to the termination 
of the case. 

Prognosis. — -We are scarcely in possession of a sufficiently large 
number of observations to justify any very accurate conclusions as 
to the risk attending albuminuria during pregnancy, but it is certainly 
by no means slight. One source of danger is that the morbid state 
of the kidneys may become permanent, and may lead to the estab- 
lishment of Bright's disease after the pregnancy is over. Goubeyre 
estimated that 49 per cent, of primiparse who have albuminuria, and 
who escape eclampsia, die from morbid conditions traceable to the 
albuminuria. This conclusion is probably much exaggerated, but if 
it even approximates to the truth, the danger must be very great. 

Tendency to produce Ahortion. — Besides the ultimate risk to the 
mother, albuminuria strongly predisposes to abortion, no doubt on 
account of the imperfect nutrition of the foetus by blood impoverished 
by the drain of albuminous materials through the kidneys. This 
fact has been observed by many writers. A good illustration of it 
is given by Tanner, 1 who states that four out of seven women he at- 
tended suffering from Bright's disease during pregnancy, aborted, one 
of them three times in succession. 

Symptoms. — The symptoms accompanying albuminuria in preg- 
nancy are by no means uniform or constantly present. That which 
most frequently causes suspicion is the anasarca — not only the cede- 
matous swelling of the lower limbs which is so common a consequence 
of the pressure of the gravid uterus, but also of the face and upper 
extremities. Any puffiness or infiltration about the face, or any 
oedema about the hands or arms, should always give rise to suspicion, 
and lead to a careful examination of the urine. Sometimes this is 
carried to an exaggerated degree, so that there is anasarca of the 
whole body. 

Anomalous nervous symptoms — such as headache, transient dizzi- 
ness, dimness of vision, spots before the eyes, inability to see objects 
distinctly, sickness in women not at other times suffering from 
nausea, sleeplessness, irritability of temper — are also often met with, 
sometimes to a slight degree, at others very strongly developed, and 

1 Signs and Diseases of Pregnancy, p. 428. 



DISEASES OF PREGNANCY. 195 

should always arouse suspicion. Indeed, knowing as we do that 
many morbid states may be associated with albuminuria, we should 
make a point of carefully examining the urine of all patients in 
whom any unusual morbid phenomena show themselves during 
pregnancy. 

Character of the Urine. — The condition of the urine varies con- 
siderably, but it is generally scanty and highly colored, and, in 
addition to the albumen, especially in cases in which the albuminuria 
has existed for some time, we may find epithelium cells, tube casts, 
and occasionally blood corpuscles. 

Treatment. — The treatment must be based on what has been said 
as to the causes of the albuminuria. Of course it is out of our power 
to remove the pressure of the gravid uterus, except by inducing 
labor ; but its effects may at least be lessened by remedies tending 
to promote an increased secretion of urine, and thus diminishing the 
congestion of the renal vessels. The administration of saline diure- 
tics, such as the acetate of potash, or bitartrate of potash, the latter 
being given in the form of the well-known imperial drink, will best 
answer this indication. The action of the bowels may be solicited 
by purgatives producing watery motions, such as occasional doses of 
the compound jalap powder. Dry cupping over the loins, frequently 
repeated, has a beneficial effect in lessening the renal hyperemia, 
The action of the skin should also be promoted by the use of the 
vapor bath, and with this view the Turkish bath may be employed 
with great benefit and perfect safety. The next indication is to 
improve the condition of the blood by appropriate diet and medica- 
tion. A very light and easily assimilated diet should be ordered, of 
which milk should form the staple. Tarnier 1 has recorded several 
cases in which a purely milk diet was very successful in removing 
albuminuria. With the milk we may allow white of egg, or a little 
white fish. The tincture of the perchloride of iron is the best medi- 
cine we can give, and it may be advantageously combined with small 
doses of tincture of digitalis, which acts as an excellent diuretic. 

Question of Inducing Labor. — Finally, in obstinate cases we shall 
have to consider the advisability of inducing premature labor. The 
propriety of this procedure in the albuminuria of pregnancy has of 
late years been much discussed, and I believe that, having in view 
the undoubted risks which attend this complication, the operation is 
unquestionably indicated, and is perfectly justifiable, in all cases at- 
tended with symptoms of gravity. It is not easy to lay down any 
definite rules to guide our decision; but I should not hesitate to 
adopl this resource in all cases in which the quantity <>!' albumen is 
considerable and progressively increasing, and in which treatmenl 
has failed to lessen the amount; and, above all, in ever)- case attended 
with threatening symptoms, such as Bevere headache, dizzine* 
loss of sight. The risks of tic operation are infinitesimal compared 

to those which tin.' patient would run in the event of puerperal con- 
vulsions supervening, of chronic Bright's disease becoming estab- 

1 Annal. de Gynec., Jan. 1876. 



196 PREGNANCY. 

listed. As the operation is seldom likely to be indicated until the 
child has reached a viable age, and as the albuminuria places the 
child's life in danger, we are quite justified in considering the mother's 
safety alone in determining on its performance. 



CHAPTEE VIII. 

DISEASES OF PREGNANCY (CONTINUED). 

Disorders of the Nervous System. — There are many disorders of the 
nervous system met with during the course of pregnancy. Among 
the most common are morbid irritability of temper, or a state of 
mental despondency and dread of the results of the labor, sometimes 
almost amounting to insanity, or even progressing to actual mania. 
These are but exaggerations of the highly susceptible state of the 
nervous system generally associated with gestation. Want of sleep 
is not uncommon, and, if carried to any great extent, may produce 
serious trouble from the irritability and exhaustion it produces. In 
such cases we should endeavor to lessen the excitable state of the 
nerves, by insisting on the avoidance of late hours, over-much society, 
exciting amusements, and the like ; while it may be essential to pro- 
mote sleep by the administration of sedatives, none answering so well 
as the chloral hydrate, in combination with large doses of the bro- 
mide of potassium, which greatly intensifies its hypnotic effects. 
[Bromide of sodium, since its reduction in price, being more soluble, 
more purely saline, more active, and more grateful to the stomach, 
is gradually supplanting in a measure the salt of potash. — Ed.] 

Headaches and Neuralgia. — Severe headaches and various intense 
neuralgias are common. Amongst the latter the most frequently 
met with are pain in the breasts, due to the intimate sympathetic 
connection of the mammas with the gravid uterus ; and intense inter- 
costal neuralgia, which a careless observer might mistake for pleu- 
ritic or inflammatory pain. The thermometer, by showing that there 
is no elevation of temperature, would prevent such a mistake. Neu- 
ralgia of the uterus itself, or severe pains in the groins or thighs — 
the latter being probably the mechanical results of dragging on the 
attachments of the abdominal muscles — are also far from uncommon. 
In the treatment of such neuralgic affections attention to the state of 
the general health, and large doses of quinine and ferruginous pre- 
parations whenever there is much debility, will be indicated. Locally 
sedative applications, such as belladonna and chloroform liniments ; 
friction with aconite ointment when the pain is limited to a small 
space ; and, in the worst cases, the subcutaneous injection of mor- 
phia, will be called for. Those pains which apparently depend on 



DISEASES OF PREGNANCY. 197 

mechanical causes may often be best relieved by lessening the trac- 
tion on the muscles, by wearing a well-made elastic belt to support 
the uterus. 

Paralysis depending on Pregnancy. — Among the most interesting 
of the nervous diseases are various paralytic affections. Almost all 
varieties of paralysis have been observed, such as paraplegia, hemi- 
plegia (complete or incomplete), facial paralysis, and paralysis of the 
nerves of special sense, giving rise to amaurosis, deafness, and loss of 
taste. Churchill records 22 cases of paralysis during pregnancy, 
collected by him from various sources. A large number have also 
been brought together by Imbert Goubeyre, 1 in an interesting memoir 
on the subject, and others are recorded by Ford} r ce Barker, Joulin, 
and other authors ; so that there can be no doubt of the fact that 
paralytic affections are common during gestation. In the large pro- 
portion of the cases recorded the paralyses have been associated 
with albuminuria, and are doubtless uraemic in origin. Thus in 19 
cases, related by Goubeyre, albuminuria was present in all. The 
dependency of the paralysis on a transient cause, explains the fact 
that in the large majority of these cases the paralysis was not per- 
manent, but disappeared shortly after labor. In every case of par- 
lysis, whatever be its nature, special attention should be directed to 
the state of the urine, and, should it be found to be albuminous, 
labor should be at once induced. This is clearly the proper course 
to pursue, and we should certainly not be justified in running the 
risk that must attend the progress of a case in which so formidable 
a symptom has already developed itself. When the cause has been 
removed, the effect will also generally rapidly disappear, and the 
prognosis is therefore, on the whole, favorable. Should the paralysis 
continue after delivery, the treatment must be such as we would 
adopt in the non-pregnant state ; and small doses of strj^chnia, along 
with faradization of the affected limbs, would be the best remedy at 
our disposal. 

Paralyses which are not Urvemic in their Origin. — There are, how- 
ever, unquestionably some cases of puerperal paralysis which are not 
uraemic in their origin, and the nature of which is somewhat obscure. 
Hemiplegia may doubtless be occasioned by cerebral hemorrhage, as 
in the non-pregnant state Other organic causes of paralysis, such 
as cerebral congestion, or embolism, may, now and again, be met 
with during pregnancy, but cases of this kind must be of compara- 
tive rarity. Other cases are functional in their origin. Tarnier 
relates a case of hemiplegia which he could only refer to extreme 
anaemia. Some, again, may be hysterical. Paraplegia is apparently 
more frequently unconnected with albuminuria than the other forms 
of paralysis ; and it may cither depend on pressure of the gravid 
uterus on the nerves as they pass through the pelvis, or on reflex 
action, as is sometimes observed in connection with uterine disease 
When, in Buch cases, the absence of albuminuria is ascertained by 
frequent examination of the urine, there is obviously no1 the same 

1 M6m. de I' Acad, de M£d., 1801. 



198 PREGNANCY. 

risk to the patient as in cases depending on uraemia, and therefore it 
may be justifiable to allow pregnancy to go on to term, trusting to 
subsequent general treatment to remove the paralytic symptoms. 
As the loss of power here depends on a transient cause, a favorable 
prognosis is quite justifiable. [Partial paralysis of one lower ex- 
tremity, generally the left, sometimes occurs, from pressure of the 
foetal occiput, and may continue for some days or weeks, with a 
gradual improvement, after parturition. — Ed.] 

Chorea is not infrequently observed, and forms a serious complica- 
tion. It is generally met with in young women of delicate health, 
and in the first pregnancy. In a large proportion of the cases the 
patient has already suffered from the disease before marriage. On 
the occurrence of pregnancy, the disposition to the disease again 
becomes evoked, and choreic movements are re-established. This 
fact may be explained partly by the susceptible state of the nervous 
system, partly by the impoverished condition of the blood. 

Prognosis. — That chorea is a dangerous complication of pregnancy 
is apparent by the fact that out of 56 cases collected by Dr. Barnes, 1 
in an excellent paper on the subject, no less than 17, or 1 in 3, proved 
fatal. Nor is it danger to life alone that is to be feared, for it ap- 
pears certain that chorea is more apt to leave permanent mental dis- 
turbance when it occurs during pregnancy, than at other times. It 
has also an unquestionable tendency to bring on abortion or prema- 
ture labor, and in most cases the life of the child is sacrificed. 

Treatment. — The treatment of chorea during pregnancy does not 
differ from that of the disease under more ordinary circumstances ; 
and our chief reliance will be placed on such drugs as the liquor 
arsenicalis, bromide of potassium, and iron. In the severe form of 
the disease, the incessant movements, and the weariness and loss of 
sleep, may very seriously imperil the life of the patient, and more 
prompt and radical measures will be indicated. . If, in spite of our 
remedies, the paroxysms go on increasing in severity, and the 
patient's strength appears to be exhausted, our only resource is to 
remove the most evident cause by inducing labor. Generally the 
symptoms lessen and disappear soon after this is done. There can 
be no question that the operation is perfectly j astiflable, and may 
even be essential under such circumstances. It should be borne in 
mind that the chorea often recurs in a subsequent pregnancy, and 
extra care should then always be taken to prevent its development. 

Disorders of the urinary organs are of frequent occurrence. Be- 
tention of urine may be met with, and this is often the result of a 
retroverted uterus. The treatment, therefore, must then be directed 
to the removal of the cause. This subject will be more particularly 
considered when we come to discuss that form of displacement (p. 
203) ; but we may here point out that retention of urine, if long con- 
tinued, may not only lead to much distress, but to actual disease of 
the coats of the bladder. Several cases have been recorded in which 
cystitis, resulting from urinary retention in pregnancy, eventually 

1 Obst. Trans., vol. x. 



DISEASES OF PREGNANCY. 199 

caused the exfoliation of the entire mucous membrane of the blad- 
der, 1 which was cast off, sometimes entire, sometimes in shreds, and 
occasionally with portions of the muscular coat attached to it. The 
possibility of this formidable accident should teach us to be careful 
not to allow any undue retention of urine, but, by a timely use of 
the catheter, to relieve the symptoms, while we, at the same time, 
endeavor to remove the cause. 

Irritability of the bladder is of frequent occurrence. In the early 
months it seems to be the consequence of sympathetic irritation of 
the neck of the bladder, combined with pressure, while in the later 
months it is, probably, solely produced by mechanical causes. When 
severe it leads to much distress, the patient's rest being broken and 
disturbed by incessant calls to micturate, and the suffering induced 
may produce serious constitutional disturbances. I have elsewhere 
pointed out, 2 that irritability of the bladder in the latter months of 
pregnancy is frequently associated with an abnormal position of the 
foetus, which is placed transversely or obliquely. The result is either 
that undue pressure is applied to the bladder, or that it is drawn out 
of its proper position. [Where the foetus is anencephalus, with the 
defective head presenting, the calls to urinate are in some cases a very 
serious annoyance, as the foetus makes an unusual pressure directly 
on the bladder. — Ed.] The abnormal position of the foetus can 
readily be detected by palpation, and as readily altered by external 
manipulation. In some of the cases I have recorded, altering the 
position of the foetus was immediately folloAved by relief; the symp- 
toms recurring after a time, when the foetus had again assumed an 
oblique position. Should the foetus frequently become displaced, an 
endeavor may be made to retain it in the longitudinal axis of the 
uterus by a proper adaptation of bandages or pads. In cases not 
referable to this cause we should attempt to relieve the bladder symp- 
toms by appropriate medication, such as small doses of liquor potassre, 
if the urine be very acid ; tincture of belladonna ; the decoction of 
triticum repens, an old but very serviceable remedy; and vaginal 
sedative ]>■ -varies containing morphia or atropine. 

Incontinence of Urine. — Women who have borne many children 
are often troubled with incontinence of urine during pregnancy, the 
water dribbling away on the slightest movement. Through this 
much irritation of the skin surrounding the genitals is produced, at- 
tended with troublesome excoriations and eruptions. Relief may be 
partially obtained by lessening the pressure on the bladder by an 
abdominal belt, while the skin is protected by applications of Bimple 
ointment or glycerine. 

Phosphatic Deposit.-— Dr. Tyler Smith has directed attention to a 
phosphatic condition of the urine occurring in delicate women, whose 
constitutions are severely tried by gestation. This condition can 
easily be altered by rest, nutritious diet, and a course of restorative 
medicines, such as steel, mineral acids, and the like. 

1 Obst. Trans., vol. XL 2 Obst. Trans, vol. x iii. 



200 PREGNANCY, 

Leucorrhoea. — A profuse whitish, leucorrhoeal discharge is very 
common during pregnancy, especially in its latter half. The discharge 
frequently alarms the patient, but, unless it is attended with disa- 
greeable symptoms, it does not call for special treatment. When at 
all excessive, it may lead to much irritation of the vagina and ex- 
ternal generative organs. The labia may become excoriated and 
covered with small aphthous patches, and the whole vulva may be 
hot, swollen, and tender. Warty growths, similar in appearance to 
syphilitic condylomata, are occasionally developed in pregnant women, 
unconnected with any specific taint, and associated with the presence 
of an irritating leucorrhoeal discharge. According to Thibierge, 1 
these resist local applications, such as sulphate of copper or nitrate 
of silver, but spontaneously disappear after delivery. Inasmuch as 
the leucorrhoeal discharge is dependent on the congested condition of 
the generative organs accompanying pregnancy, we can hope to do 
little more than alleviate it. In the severer forms, as has been pointed 
out by Henry Bennet, the cervix will be found to be abraded or 
covered with granular erosion, and it may be, from time to time, 
cautiously touched with the nitrate of silver, or a solution of carbolic 
acid. Generally speaking, we must content ourselves with recom- 
mending the patient to wash the vagina out gently with diluted 
Condy's fluid; or with a solution of the sulpho-carbolate of zinc, of 
the strength of four grains to the ounce of water ; or with plain tepid 
water. For obvious reasons frequent and strong vaginal douches are 
to be avoided, but a daily gentle injection, for the purpose of ablution, 
can do no harm. 

Pruritus. — A very distressing pruritus of the vulva is frequently 
met with along with leucorrhoea, especially when the discharge is of 
an acrid character, which in some cases leads to intense and protracted 
suffering, forcing the patient to resort to incessant friction of the parts. 
Pruritus, however, may exist without leucorrhoea, being apparently 
sometimes of a neuralgic character, at others associated with apthous 
patches on the mucous membrane, ascarides in the rectum, or pediculi 
in the hairs of the mons veneris and labia. Cases are even recorded 
in which the pruritic irritation extended over the whole body. The 
treatment is difficult and unsatisfactory. Yarious sedative applica- 
tions may be tried, such as weak solutions of Goulard's lotion; or a 
lotion composed of an ounce of the solution of the muriate of morphia, 
with a drachm and a half of hydrocyanic acid, in six ounces of water; 
or one formed by mixing one part of chloroform with six of almond 
oil. A very useful form of medication consists in the insertion into 
the vagina of a pledget of cotton-wool, soaked in equal parts of the 
glycerine of borax and sulphurous acid. This may be inserted at 
bed time, and withdrawn in the morning by means of a string attached 
to it. In the more obstinate cases, the solid nitrate of silver may be 
lightly brushed over the vulva; or, as recommended by Tarnier, a 
solution of bichloride of mercury, of about the strength of two grs. 
to the ounce, may be applied night and morning. The state of the 

1 Arch. G6n, de M6d., 1856. 



DISEASES OF PREGNANCY. 201 

digestive organs should always be attended to, and aperient mineral 
water may be usefully administered. When the pruritus extends 
beyond the vulva, or even in severe local cases, large doses of bromide 
of potassium may perhaps be useful in lessening the general hyper - 
aesthetic state of the nerves. 

Effects of Pressure. — Some of the disorders of pregnancy are the 
direct results of the mechanical pressure of the gravid uterus. The 
most common of these are oedema and a varicose state of the veins of 
the lower extremities, or even of the vulva. The former is of little 
consequence, provided we have assured ourselves that it is really the 
result of pressure, and not of albuminuria, and it can generally be 
relieved by rest in the horizontal position. A varicose state of the 
veins of the lower limbs is very common, especially in multipara?, in 
whom it is apt to continue after delivery. Occasionally the veins of 
the vulva, and even of the vagina, are also enlarged and varicose, 
producing considerable swelling of the external genitals. Eest in 
the recumbent position, and the use of an abdominal belt, so as to 
take the pressure off the veins as much as possible, are all that can 
be done to relieve this troublesome complication. If the veins of the 
legs are much swollen, some benefit may be derived from an elastic 
stocking or a carefully applied bandage. 

Occasional serious results from Laceration of the Veins. — Serious and 
even fatal consequences have followed the accidental laceration of 
the swollen veins. When laceration occurs during or immediately 
after delivery — a not uncommon result of the pressure of the head — 
it gives rise to the formation of a vaginal thrombus. It has occa- 
sionally happened from an accidental injury during pregnanc} r , as in 
the cases recorded by Simpson, in which death followed a kick on 
the pudenda, producing laceration of a varicose vein, or in one men- 
tioned by Tarnier, where the patient fell on the edge of a chair. 
Severe hemorrhage has followed the accidental rupture of a vein in 
the leg. The only satisfactory treatment is pressure, applied directly 
to the bleeding parts by means of the finger, or by compresses satu- 
rated in a solution of the perchloride of iron. The treatment of 
vaginal thrombus following labor must be considered elsewhere. 
Occasionally the varicose veins inflame, become very tender and 
painful, and coagula form in their canals. In such cases absolute 
rest should be insisted on, while sedative lotions, such as the chloro- 
form and belladonna Liniments, should be applied to relieve the pain. 

Displacements of the Gravid Uterus. — Certain displacements of the 
gravid uterus an- tnel with, which may give rise to Bymptoms of 
great gravity. 

Prolapse, which Is pare, is almosl always the resull of pregnancy 
occurring in a uterus which had been previously more or less proci- 
dent. Under such circumstances the increasing weighl of the uterus 
will at first necessarily augmenl the previously existing tendency to 
protrusion of the \v<>ml>. which may come t<> protrude partially or 
entirely bej'ond the vulva. In the great majority of cases, a- preg- 
nancy advances, the prolapsus cures itself, for a1 aboul tin- fourth or 
fifth month the uterus will rise above the pelvic brim. It has been 
14 



202 PREGNANCY. 

said, that, in some cases of complete procidentia, pregnancy lias gone 
on even to term, with the uterus lying entirely outside the vulva. 
Most probably these cases were imperfectly observed, the greater 
part of the uterus being in reality above the pelvic brim, a portion 
only of its lower segment protruding externally; or, as has some- 
times been the case, the protruding portion has been an old standing 
hypertrophic elongation of the cervix, the internal os uteri and fundus 
being normally situated. Should a prolapsed uterus not rise into 
the abdominal cavity as pregnancy advances, serious symptoms will 
be apt to develop themselves ; for, unless the pelvis be unusually 
capacious, the enlarging uterus will get jammed within its bony 
walls, the rectum and urethra will be pressed upon, defecation and 
micturition will be consequently impeded, and severe pain and much 
irritation will result. In all probability such a state of things would 
lead to abortion. The possibility of these consequences should, there- 
fore, teach us to be careful in the management of every case of prolap- 
sus, however slight, in which pregnancy occurs. Absolute rest, in the 
horizontal position, should be insisted on ; while the uterus should 
be supported in the pelvis by a full-sized Hodge's pessary, which 
should be worn until at least the sixth month, when the uterus would 
be fully within the abdominal cavity. After delivery, prolonged 
rest should be recommended, in the hope that the process of involu- 
tion may be accompanied by a cure of the prolapse. There can be 
no doubt that pregnancy carried to term affords an opportunity of 
curing even old-standing displacements, which should not be neg- 
lected. 

Anteversion of the gravid uterus seldom produces symptoms of 
consequence. In all probability it is common enough when preg- 
nancy occurs in a uterus which is more than usually anteverted, or 
is anteflexed. Under such circumstances, there is not the same risk 
of incarceration in the pelvic cavity as in cases in which pregnancy 
exists in a retroflexed uterus, for, as the uterus increases in size, it 
rises without difficulty into the abdominal cavity. In the early 
months the pressure of the fundus on the bladder may account for 
the irritability of that viscus then so commonly observed. It will 
be remembered that (xraily Hewitt attributes great importance to 
this condition as explaining the sickness of pregnancy — a theory, 
however, which has not met with general acceptation. 

Extreme anteversion of the uterus ) at an advanced period of preg- 
nancy, is sometimes observed in multiparas with very lax abdominal 
walls, occasionally to such an. extent that the uterus falls completely 
forwards and downwards, so that the fundus is almost on a level 
with the patient's knees. This form of pendulous belly may be 
associated with a separation of the recti muscles, between which the 
womb forms a ventral hernia, covered only by the cutaneous textures. 
When labor comes on this variety of displacement may give rise to 
trouble by destroying the proper relation of the uterine and pelvic 
axes. The treatment is purely mechanical, keeping the patient lying 
on her back as much as possible, and supporting the pendulous abdo- 
men by a properly adjusted bandage. A similar forward displace- 



DISEASES OF PREGNANCY. 203 

ment is observed in cases of pelvic deformity, and in the worst forms, 
in rachitic and dwarfed women, it exists to a very exaggerated de- 
gree. [This uterine hernia may even be such an obstacle to parturi- 
tion as to require the Cesarean section, as in the case reported by 
Dr. Harvey, 1 of Eichmond, Mississippi, in 1849. — Ed.] 

Retroversion. — The most important of the displacements, in conse- 
quence of its occasional very serious results, is retroversion of the 
gravid uterus. It was formerly generally believed that this was 
most commonly produced by some accident, such as a fall, which 
dislocated a uterus previously in a normal position. Undue dis- 
tension of the bladder was also considered to have an important 
influence in its production, by pressing the uterus backwards and 
downwards. 

Its Causes. — It is now almost universally admitted that, although 
the above-named causes may possibly sometimes produce it, in the 
very large proportion of cases it depends on pregnancy having 
occurred in a uterus previously retroverted or retroflexed. The- 
merit of pointing out this fact unquestionably belongs to the late 
Dr. Tyler Smith, and further observations have fully corroborated 
the correctness of his views. 

In the large majority of cases in which pregnancy occurs in a 
uterus so displaced, as the womb enlarges, it straightens itself, and 
rises into the abdominal cavity, without giving any particular 
trouble; or, as not infrequently happens, the abnormal position of 
the organ interferes so much with its enlargement as to produce 
abortion. Sometimes, however, the uterus increases without leaving 
the pelvis until the third or fourth month, when it can no longer be 
retained in the pelvic cavity without inconvenience. It then presses 
on the urethra and rectum, and eventually becomes completely in- 
carcerated within the rigid walls of the bony pelvis, giving rise to 
characteristic symptoms. 

Symptoms. — The first sign which attracts attention is generally 
some trouble connected with micturition, in consequence of pressure 
on the urethra. On examination, the bladder will often be found to 
be enormously distended, forming a large, fluctuating abdominal 
tumor, which the patient has lost all power of emptying. Fre- 
quently small quantities of urine dribble away, leading the woman 
to believe that she has passed water, and thus the distension is often 
overlooked. Sometimes the obstruction to the discharge of urine is 
so greal as to lead to dropsical effusion into the cellular tissue of the 
arms and legs. This was very well marked in one of my cases, and 
disappeared rapidly after the bladder had been emptied. Difficulty 
in defecation, tenesmus, obstinate constipation, and inability to empty 
the bowels, becomes established aboul the same time. These symp- 
toms increase, accompanied by some pelvic pain and a sense of weight 
and bearing down, until at last the patienl applies for advice, and 
the true nature of the ease is detected. When the retroversion, 

[' New Orleans Med. and Surg. Journal, vol. Ex. p. 772, is;,::.] 



204 PEEGNANCY. 

occurs suddenly, all these symptoms develop with, great rapidity, 
and are sometimes very serious from the first. 

Progress and Termination. — The further progress is various. 
Sometimes, after the uterus has been incarcerated in the pelvis for 
more or less time, it may spontaneously rise into the abdominal 
cavity, when all threatening symptoms will disappear. So happy a 
termination is quite exceptional, and if the practitioner should not 
interfere and effect reposition of the organ, serious and even fatal 
consequences may ensue, unless abortion occurs. 

Termination if Reduction is not Effected. — The extreme distension 
of the bladder, and the impossibility of relieving it, may lead to 
lacerations of its coats, and fatal peritonitis ; or the retention of urine 
may produce cystitis, with exfoliation of the coats of the bladder ; 
or, as more commonly happens, retention of urinary elements may 
take place, and death occur with all the symptoms of uraemic poison- 
ing. At other times the impacted uterus becomes congested and 
inflamed, and eventually sloughs, its contents, if the patient survive, 
being discharged by fistulous communications into the rectum and 
vagina. It need hardly be said that such terminations are only possi- 
ble in cases which have been grossly mismanaged, or the nature of 
which has not been detected till a late period. 

Diagnosis. — The diagnosis is not difficult. On making a vaginal 
examination, the finger impinges on a smooth rounded elastic swell- 
ing, filling up the lower part of the pelvis, and stretching and de- 
pressing the posterior vaginal wall, which occasionally protrudes 
beyond the vulva. On passing the finger forwards and upwards we 
shall generally be able to reach the cervix, high up behind the pubes, 
and pressing on the urethral canal. In very complete retroversion 
it may be difficult or impossible to reach the cervix at all. On ab- 
dominal examination the fundus uteri cannot be felt above the pelvic 
brim ; this, as the retroversion does not give rise to serious symp- 
toms until between the third and fourth months, should, under 
natural circumstances, always be possible. By bi-manual examina- 
tion we can make out, with due care, the alternate relaxation and 
contraction of the uterine parietes characteristic of the gravid uterus, 
and so differentiate the swelling from any other in the same situa- 
tion. The accompanying phenomena of pregnancy will also prevent 
any mistake of this kind. 

Retroversion going on to Term. — In some few cases retroversion has 
been supposed to go on to term. Strictly speaking, this is impossi- 
ble ; but in the supposed examples, such as in the well-known case 
recorded by Oldham, part of a retroflexed uterus remained in the 
pelvic cavity, while the greater part developed in the abdominal 
cavity. The uterus is, therefore, divided, as it were, into two por- 
tions ; one, which is the flexed fundus, remaining in the pelvis, the 
other, containing the greater part of the foetus, rising above it. 
Under these circumstances, a tumor in the vagina would exist in 
combination with an abdominal tumor, and pregnancy might go on 
to term. Considerable difficulty may even arise in labor, but the 



DISEASES OF PREGNANCY. 205 

malposition generally rectifies itself before it gives rise to any serious 
results. 

Treatment. — The treatment of retroversion of the gravid uterus 
should be taken in hand as soon as possible, for every day's delay 
involves an increase in the size of the uterus, and, therefore, greater 
difficulty in reposition. Our object is to restore the natural direc- 
tion of the uterus, by lifting the fundus above the promontory of the 
sacrum. The first thing to be done is to relieve the patient by 
emptying the bladder, the retention of urine having probably origi- 
nally called attention to the case. For this purpose it is essential to 
use a long elastic male catheter of small size, as the urethra is too 
elongated and compressed to admit of the passage of the ordinary 
silver instrument. Even then it may be extremely difficult to intro- 
duce the catheter, and sometimes it has been found to be quite im- 
possible. Under such circumstances, provided reposition cannot be 
effected without it, the bladder may be punctured an inch or two 
above the pubes by means of the fine needle of an aspirator, and the 
urine drawn off. Dieulafoy's work on aspiration proves conclusively 
that this may be done without risk, and the operation has been suc- 
cessfully performed by Schatz and others. It very rarely happens, 
however, and in long-neglected cases only, that the withdrawal of 
the urine is found to be impossible. 

Mode of Effecting Reduction. — The bladder being emptied, and the 
bowels being also opened, if possible, by copious enemata, we pro- 
ceed to attempt reduction. For this purpose various procedures are 
adopted. If the case is not of very long standing, I am inclined to 
think that the gentlest and safest plan is the continuous pressure of 
a caoutchouc bag, filled with water, placed in the vagina. The good 
effects of steady and long-continued pressure of this kind were 
proved by Tyler Smith, who effected in this way the reduction of an 
inverted uterus of long standing, and it is not difficult to understand 
that it may succeed when a more sudden and violent effort fails. I 
have tried this plan successfully in two cases, a pyriform India-rub- 
ber bag being inserted into the vagina, and distended as far as the 
patient could bear by means of a syriuge. The water must be let out 
occasionally to allow the patient to empty the bladder, and the bag 
immediately refilled. In both my cases reposition occurred within 
twenty-four hours. Barnes has failed with this method ; but it suc- 
ceeded so well in my cases, and is so obviously less likely to prove 
hurtful than forcible reposition with the hand, that I am inclined to 
consider it the preferable procedure, and one that should be tried 
first. Failing with the fluid pressure, we should endeavor to replace 
the uterus in the following way. The patient should be placed at 
the edge of the bed, in the ordinary obstetric position, and thoroughly 
anaesthetized. This is of importance, as it relaxes all the parts, and 
admits of much freer manipulation than is otherwise possible. One 
or more fingers of the left hand are then inserted into the rectum ; 
if the patient be deeply chloroformed, it is quite possible, with due 
care, even to pass the whole hand, and an attempt is then made to 
lift or push the fundus above the promonotory of the sacrum. At 



206 PREGNANCY. 

the same time reposition is aided by drawing down the cervix with, 
the ringers of the right hand per vaginam. It has been insisted 
that the pressure should be made in the direction of one or other 
sacro-iliac synchondrosis rather than directly upwards, so that the 
uterus may not be jammed against the projection of the promontory 
of the sacrum. Failing reposition through the rectum, an attempt 
may be made per vaginam, and for this some have advised the up- 
ward pressure of the closed fist passed into the canal. Others recom- 
mend the hand and position as facilitating reposition, but this pre- 
vents the administration of chloroform, which is of more assistance 
than any change of position can possibly be. Various complex in- 
struments have been invented to facilitate the operation, but they are 
all more or less dangerous, and are unlikely to succeed when manual 
pressure has failed. 

As soon as the reduction is accomplished, subsequent descent of 
the uterus should be prevented by a large-sized Hodge's pessary, and 
the patient should be kept at rest for some days, the state of the 
bladder and bowels being particularly attended to. When reposition 
has been fairly effected, a relapse is unlikely to occur. 

Treatment when Reduction is found Impossible. — In cases in which 
reduction is found to be impossible, our only resource is the artificial 
induction of abortion. Under such circumstances this is imperatively 
called for. It is best effected by puncturing the membranes, the dis- 
charge of the liquor amnii of itself lessening the size of the uterus, 
and thus diminishing the pressure to which the neighboring parts 
are subjected. After this reposition may be possible, or we may 
wait until the foetus is spontaneously expelled. It is not always easy 
to reach the os uteri, although we can generally do so with a curved 
uterine sound. If we cannot puncture the membranes, the liquor 
amnii may be drawn off through the uterine walls by means of the 
aspirator, inserted through either the rectum or vagina. The injury 
to the uterine walls thus inflicted is not likely to be hurtful, and the 
risk is certainly far less than leaving the case alone. Naturally so 
extreme a measure would not be adopted until all the simpler means 
indicated have been tried and failed. 

Diseases coexisting with Pregnancy. — The pregnant woman is, of 
course, liable to contract the same diseases as in the non-pregnant 
state, and pregnancy may occur in women already the subject of 
some constitutional disease. There is no doubt yet much to be learned 
as to the influence of coexisting disease on pregnancy. It is certain 
that some diseases are but little modified by pregnancy, and that 
others are so to a considerable extent ; and that the influence of the 
disease on the foetus varies much. The subject is too extensive to 
be entered into at any length, but a few words may be said as to 
some of the more important affections that are likety to be met with. 

Eruptive Fevers. Smallpox. — The eruptive fevers have often very 
serious consequences, proportionate to the intensity of the attack. 
Of these variola has the most disastrous results, which are related in 
the writings of the older authors, but which are, fortunately, rarely 
seen in these daj^s of vaccination. The severe and confluent forms 



DISEASES OF PREGNANCY. 207 

of the disease are almost certainly fatal to both the mother and 
child. In the discrete form, and in modified smallpox after vaccina- 
tion, the patient generally has the disease favorably, and, although 
abortion frequently results, it does not necessarily do so. 

Scarlet Fever. — If scarlet fever of an intense character attacks a 
pregnant woman, abortion is likely to occur, and the risks to the 
mother are very great. The milder cases run their course without 
the production of any untoward symptoms. Should abortion occur, 
the well-known dangerous effect of this zymotic disease after delivery 
will gravely influence the prognosis. Cazeaux was of opinion that 
pregnant women are not apt to contract the disease; while Mont- 
gomery thought that the poison when absorbed during pregnancy 
might remain latent until delivery, when its characteristic effects 
were produced. 

Measles, unless very severe, often runs its course without seriously 
affecting the mother or child. I have myself seen several examples 
of this. De Tourcoing, however, states that out of 15 cases the 
mothers aborted in 7, these being all very severe attacks. Some 
cases are recorded in which the child was born with the rubeolous 
eruption upon it. 

Continued Fevers. — The pregnant woman may be attacked with 
any of the continued fevers, and, if they are at all severe, they are 
apt to produce abortion. Out of 22 cases of typhoid, 16 aborted, 
and the remaining 6, who had slight attacks, went on to term ; out 
of 63 cases of relapsing fever, abortion or premature labor occurred 
in 23. According to Schweden the main cause of danger to the 
foetus in continued fevers is the hyperpyrexia, especially when the 
maternal temperature reaches 104° or upwards. The fevers do not 
appear to be aggravated as regards the mother, and the same ob- 
servation has been made by Cazeaux with regard to this class of 
disease occurring after delivery. 

Pneumonia seems to be specially dangerous, for of 15 cases collected 
by Grisolle 1 11 died — a mortality immensely greater than that of the 
disease in general. The larger proportion also aborted, the children 
being generally dead, and the fatal result is probably due, as in the 
severe continued fevers, to hyperpyrexia. The cause of the maternal 
mortality does not seem quite apparent, since the same danger does 
not appear to exist in severe bronchitis, or other inflammatory 
affections. 

Phthisis. — Contrary to the usually received opinion it appears 
certain that pregnancy has no retarding influence on coexisting 
phthisis, nor does the disease necessarily advance with greater 
rapidity after delivery. Out of 27 cases of phthisis, collected by 
Grisolle, 2 24 showed the first symptoms of the disease after pregnancy 
had commenced. Phthisical women are not apt to conceive ; a fact 
which may probabty be explained by the frequent coexistence, in 
such cases, of uterine disease, especially severe leucorrhoea. The 
entire duration of the phthisis seems to be shortened, as it averaged 

1 Arch. Gen. de Med. vol. xiii. p. 298. 2 Ibid. vol. xxii. 



208 PREGNANCY. 

only nine and a half months in the 27 cases collected — a fact which 
proves, at least, that pregnancy has no material influence in arresting 
its progress. If we consider the tax on the vital powers which 
pregnancy naturally involves, we must admit that this view is more 
physiologically probable than the one generally received, and appa- 
rently adopted without any due grounds. 

Heart-disease. — The evil effects of pregnancy and parturition on 
chronic heart-disease have of late received much attention from 
Spiegelberg, Fritsch, Peter, and other writers. The subject has been 
ably discussed 1 in a series of elaborate papers by Dr. Angus Mac- 
Donald, which are well worthy of study. Out of 28 cases collected 
by him, 17, or 60 per cent., proved fatal. This, no doubt, is not 
altogether a reliable estimate of the probable risk of the complica- 
tion; but, at any rate, it shows the serious anxiety which the occur- 
rence of pregnancy in a patient suffering from chronic heart-disease 
must cause. Dr. MacDonald refers the evils resulting from pregnancy 
in connection with cardiac lesions to two causes: First, destruction 
of that equilibrium of the circulation, which has been established 
by compensatory arrangements; secondly, the occurrence of fresh 
inflammatory lesions upon the valves of the heart already diseased. 

The dangerous symptoms do not usually appear until after the 
first half of the pregnancy has passed, and the pregnancy seldom 
advances to term. The pathological phenomena generally met with 
in fatal cases are pulmonary congestion, especially of the bronchial 
mucous membrane, and pulmonary oedema, with occasional pneu- 
monia and pleurisy. Mitral stenosis seems to be the form of cardiac 
lesion most likely to prove serious, and next to this aortic incompe- 
tency. The obvious deduction from these facts is that heart-disease, 
especially when associated with serious symptoms, such as dyspnoea, 
palpitation, and the like, should be considered a strong contra-indica- 
tion of marriage. When pregnancy has actually occurred, all that 
can be done is to enjoin the careful regulation of the life of the 
patient, so as to avoid exposure to cold, and all forms of severe 
exertion . 

Syphilis. — The important influence of syphilis on the ovum is fully 
considered elsewhere. As regards the mother, its effects are not 
different from those at other times. It need only, therefore, be said 
that, whenever indications of syphilis in a pregnant woman exist, the 
appropriate treatment should be at once instituted and carried on 
during her gestation, not only with the view of checking the pro- 
gress of the disease, but in the hope of preventing or lessening the 
risk of abortion, or of the birth of an infected infant. So far from 
pregnancy contra-indicating mercurial treatment, there rather is a 
reason for insisting on it more strongly. As to the precise medica- 
tion, it is advisable to choose a form that can be exhibited continu- 
ously for a length of time without producing serious constitutional 
results. Small doses of the bichloride of mercury, such as one-six- 
teenth of a grain, thrice daily, or of the iodide of mercury, answer this 

1 Obstet. Journ. 1877. 



DISEASES OF PREGNANCY. 209 

purpose well ; or, in the early stages of pregnancy, the mercurial 
vapor bath, or cutaneous inunction, may be employed. 

Dr. Weber, of St. Petersburg, 1 has made some observations show- 
ing the superiority of the latter methods, which he found did not 
interfere with the course of pregnancy ; the contrary was the case 
when the mercury was administered by the mouth, probably, as he 
supposes, from disturbance of the digestive system. It must be borne 
in mind, that in married women it may sometimes be expedient to 
prescribe an anti-syphilitic course without their knowledge of its 
nature, so that inunction is not always feasible. 

Epilepsy. — The influence of pregnancy on epilepsy does not appear 
to be as uniform as might perhaps be expected. In some cases the 
number and intensity of the fits have been lessened, in others the 
disease becomes aggravated. Some cases are even recorded in which 
epilepsy appeared for the first time during gestation. On account 
of the resemblance between epilepsy and eclampsia there is a natural 
apprehension that a pregnant epileptic may suffer from convulsions 
during delivery. Fortunately, this is by no means necessarily the 
case, and labor often goes on satisfactorily without any attack. 

Jaundice, the result of acute yellow atrophy of the liver, is occa- 
sionally observed, and is said to have been sometimes epidemic. 
Independently of the grave risks to the mother, it is most likely to 
produce abortion or the death of the foetus. According to Davidson, 
it originates in catarrhal icterus, the excretion of the bile-products 
being impeded in consequence of pregnancy, and their retention 
giving rise to the foetal blood-poisoning which accompanies the 
severer forms of the disease. Slight and transient attacks of jaun- 
dice may occur, without being accompanied by any bad consequences. 
Their production is probably favored by the mechanical pressure of 
the gravid uterus on the intestines and the bile-ducts. 

Carcinoma. — The occurrence of pregnancy in a woman suffering 
from malignant disease of the uterus is by no means so rare as 
might be supposed, and must naturally give rise to much anxiety as 
to the result. The obstetrical treatment of these cases will be dis- 
cussed elsewhere. Should we be aware of the existence of the dis- 
ease during gestation, the question will arise whether we should not 
attempt to lessen the risks of delivery hj bringing on abortion or 
premature labor. The question is one which is by no means easy to 
settle. We have to deal with a disease which is certain to prove 
fatal to the mother before long, and the progress of which is proba- 
bly accelerated after labor, while the manipulations necessary to in- 
duce delivery may very unfavorably influence the diseased structures. 
Again, by such a measure we necessarily sacrifice the child, while 
we are by no means certain that we materially lessen the clanger to 
the mother. The question cannot be settled except on a considera- 
tion of each particular case. If we see the patient early in pregnancy, 
by inducing abortion we may save her the dangers of labor at term 
- — possibly of the Caesarean section — if the obstruction be great. 

1 Allo-em. Med. Cent. Zeit. Feb. 1875. 



210 PREGNANCY. 

Under such circumstances, the operation would be j ustifiable. If the 
pregnancy have advanced beyond the sixth or seventh month, unless 
the amount of malignant deposit be very small indeed, it is probable 
that the risks of labor would be as great to the mother as a term, 
and it would then be advisable to give her the advantage of the few 
months' delay. 

Ovarian Tumor. — Cases are occasionally met with in which preg- 
nancy occurs in women who are suffering from ovarian tumor, and 
their proper management has given rise to considerable discussion. 
There can be no doubt that such cases are attended with very danger- 
ous and often fatal consequences, for the abdomen cannot well ac- 
commodate the gravid uterus and the ovarian tumor, both increasing 
simultaneously. The result is that the tumor is subject to much 
contusion and pressure, which have sometimes led to the rupture of 
the cyst, and the escape of its contents into the peritoneal cavity ; at 
others to a low form of inflammation, attended with much exhaustion, 
the death of the patient supervening either before or shortly after 
delivery. The danger during delivery from the same cause, in the 
cases which go on to term, is also very great. Of 13 cases of delivery 
by the natural powers, which I collected in a paper on "Labor Com- 
plicated with Ovarian Tumor," 1 far more than one-half proved fatal. 
[A lady of Philadelphia gave birth to three living children during the 
existence of an ovarian tumor : all of the children grew up ; and the 
mother fell a victim to the disease at the age of 77, after numerous 
tappings, during fifty years. — Ed.] Another source of danger is 
twisting of the pedicle, and consequent strangulation of the cyst, of 
which several instances are recorded. It is obvious, then, that the 
risks are so manifold that in every case it is advisable to consider 
whether they can be lessened by surgical treatment. 

Methods of Treatment. — The means at our disposal are either to 
induce labor prematurely, to treat the tumor by tapping, or to per- 
form ovariotomy. The question has been particularly discussed by 
Spencer Wells in his works on " Ovariotomy," and by Barnes in his 
"Obstetric Operations." The former holds that the proper course to 
pursue is to tap the tumor when there is any chance of its being 
materially lessened in size by that procedure, but that when it is 
multilocular, or when its contents are solid, ovariotomy should be 
performed at as early a period of pregnancy as possible. Barnes, on 
the other hand, maintains that the safer course is to imitate the 
means by which nature often meets this complication, and bring on 
premature labor without interfering with the tumor. He thinks that 
ovariotomy is out of the question, and that tapping may be insuffi- 
cient and leave enough of the tumor to interfere seriously with labor. 
So far as recorded cases go, they unquestionably seem to show that 
tapping is not more dangerous than at other times, and that ovario- 
tomy may be practised during pregnancy with a fair amount of suc- 
cess. Wells records 10 cases which were surgically interfered with. 
In 1 tapping was performed, and in 9 ovariotomy ; and of these 8 
recovered, the pregnancy going on to term in 5. On the other hand, 

1 Obst. Trans., vol. ix. 



DISEASES OF PREGNANCY. 211 

5 cases were left alone, and either went to term, or spontaneous pre- 
mature labor supervened ; and of these 3 died. The cases are not 
sufficiently numerous to settle the question, but they certainly favor 
the view taken by Wells rather than that by Barnes. It is to be 
observed that, unless we give up all hope of saving the child, and 
induce abortion, the risk of induced premature labor, when the preg- 
nancy is sufficiently advanced to hope for a viable child, would almost 
be as great as that of labor at term ; for the question of interference 
will only have to be considered with regard to large tumors, which 
would be nearly as much affected by the pressure of a gravid uterus 
at seven or eight months, as by one at term. Small tumors gene- 
rally escape attention, and are more apt to be impacted before the 
presenting part in delivery. The success of ovariotomy during 
pregnancy has certainly been great, and we have to bear in mind 
that the woman must necessarily be subjected to the risk of the 
operation sooner or later, so that we cannot judge of the case as one 
in which abortion terminates the risk. Even if the operation should 
put an end to the pregnancy — and there is at least a fair chance that 
it will not do so — there is no certainty that that would increase the 
risk of the operation to the mother, while as regards the child we 
should only have the same result as if we intentionally produced 
abortion. On the whole, then, it seems that the best chance to the 
mother, and certainly the best to the child, is to resort to the appa- 
rently heroic practice recommended by Wells. The determination 
must, however, be to some extent influenced by the skill and ex- 
perience of the operator. If the medical attendant has not gained 
that experience which is so essential for a successful ovariotomist, 
the interests of the mother would be best consulted by the induction 
of abortion at as early a period as possible. One or other procedure, 
is essential ; for, in spite of a few cases in ivhich several successive 
pregnancies have occurred in women who have had ovarian tumors, 
the risks are such as not to justify an expectant practice. Should 
rupture of the cyst occur, there can be no doubt that ovariotomy 
should at once be resorted to, with the view of removing the lacerated 
cyst and its extravasated contents. 

Fibroid Tumors. — Pregnancy may occur in a uterus in which there 
are one or more fibroid tumors. If these are situated low down and 
in a position likely to obstruct the passage of the foetus, they may 
very seriously complicate delivery. When they are situated in the 
fundus or body of the uterus they may give rise to risk from hemor- 
rhage, or from inflammation of their own structure. Inasmuch as 
they are structurally similar to the uterine walls they partake of the 
growth of the uterus during pregnancy, and frequently increase re- 
markably in size. Cazeaux saj^s — " I have known them in several in- 
stances to acquire a size in three or four months which the}?" would not 
have done in several years in the non -pregnant condition." Con- 
versely, they share in the involution of the uterus after delivery, and 
often lessen greatly in size, or even entirely disappear. Of this fact I 
have elsewhere recorded several curious examples ; 1 and many other 

1 Obst. Trans., vols. v. xiii. and xix. 



212 PREGNANCY. 

instances of the complete disappearance of even large tumors have 
been described by authors whose accuracy of observation cannot be 
questioned. 

Treatment. — The treatment will vary with the position of the 
tumor. If it is such as to be certain to obstruct the passage of the 
child, abortion should be induced as soon as possible. If the tumor 
is well out of the way, this is not so urgently called for. The princi- 
pal danger then is that the tumor will impede the post-mortem con- 
traction of the uterus, and favor hemorrhage. Even if this should 
happen, the flooding could be controlled by the usual means, espe- 
cially by the injection of the perchloride of iron. I have seen several 
cases in which delivery has taken place under such circumstances 
without any untoward accident. The danger from inflammation and 
subsequent extrusion of the fibroid masses would probably be as 
great after abortion or premature labor, as after delivery at term. It 
seems, therefore, to be the proper rule to interfere when the tumors 
are likely to impede delivery, and in other cases to allow the preg- 
nancy to go on, and be prepared to cope with any complications as 
they arise. The risks of pregnancy should be avoided in every case 
in which uterine fibroids of any size exist, the patients being advised 
to lead a celibate life. 



CHAPTEE IX. 

PATHOLOGY OF THE DECIDUA AND OVUM. 

Comparatively little is, unfortunately, known of the pathological 
changes which occur in the mucous membrane of the uterus during 
pregnancy. It is probable that they are of much more consequence 
than is generally believed to be the case ; and it is certain that they 
are a frequent cause of abortion. 

Endometritis. — One of the most generally observed probably de- 
pends on endometritis antecedent to conception. When the impreg- 
nated ovule reached the uterus, it engrafted itself on the inflamed 
mucous membrane, which was in an unfit condition for its reception 
and growth. A not uncommon result, under such circumstances, is the 
laceration of some of the decidual vessels, extravasation of blood be- 
tween the decidua and the uterine walls, and consequent abortion at 
an early stage of pregnancy. As this morbid state of the uterine 
mucous membrane is likely to continue after abortion is completed, 
the same history repeats itself on each impregnation, and thus we 
may have constant early miscarriages produced. It does not neces- 
sarily follow, however, that the pregnancy is immediatedly terminated 
when this state of things is present. Sometimes a condition of 



PATHOLOGY OF THE DECIDUA AND OVUM 



213 



hyperplasia of the decidua is produced, the membrane becomes much 
thickened and hypertrophied, and the decidual cells are greatly in- 
creased in size (Fig. 82). In other instances the internal surface of 
the decidua becomes studded with rough polypoid growths, 1 depend- 



Fig. 82. 




Hypertrophied Decidua laid open, with the Ovum attached to its Fundal 
Portion. (After Duncan.) 

ing on proliferation of its interstitial tissue. Duncan has found that 
the hypertrophied decidua is always in a state of fatty degeneration, 
more advanced in some places than in others. 2 The result of these 
alterations is frequently to produce dwindling or death of the ovum, 
which, however, retains its connection with the decidua, until, after 
a lapse of time, the decidua is expelled in the form of a thick tri- 
angular fleshy substance, with the atrophied ovum attached to some 
part of its inner surface. In other cases, in which the hyperplasia 
has advanced to a less extent, the nutrition of the foetus is not inter- 
fered with, and pregnancy may continue to term, the changes in the 
decidua being recognizable after delivery. Other diseases besides 
endometritis may give rise to similar alterations in the decidua, one 
of these being, as Yirchow maintains, syphilis. The converse con- 



Vireliow's Archiv fur Path. 1868. 



Researches in Obstetrics, p. 293. 



214 



PREGNANCY, 




Imperfectly developed Decidua Yera, with the 
Ovum. (After Duncan.) 



Fig. 83. dition, and imperfect develop- 

ment of the decidua, especially 
of the decidua reflexa, has also 
been noted as a cause of abor- 
tion. The ovum will then hang 
loosely in the uterine cavity, 
without the support which the 
growth of the decidua reflexa 
around it ought to afford, and 
its premature expulsion readily 
follows (Fig. 83). 

Hydrorrhea Gravidarum. — 
The peculiar condition known 
as hydrorrhea gravidarum most 
probably depends on some ob- 
scure morbid state of the uterine 
mucous membrane. By this is 
meant a discharge of clear watery 
fluid at intervals during preg- 
nancy. It may happen at any 
period of gestation, but it is most commonly met with in the latter 
months. It may commence with a mere dribbling, or there may be 
a sudden and copious discharge of fluid. Afterwards the watery 
fluid, which is generally of a pale yellowish color, and transparent, 
like the liquor amnii, may continue to escape at intervals for many 
weeks, and sometimes in very great abundance, so as to saturate the 
patient's clothes. Yery frequently it is expelled in gushes, and at 
night, when the patient is lying quietly in bed ; its escape is then 
probably due to uterine contraction. 

Many theories have been held as to its cause. By some it is 
attributed to the rupture of a cyst placed between the ovum and the 
uterine walls ; Baudelocque referred it to a transudation of the liquor 
amnii through the membranes ; while Burgess and Dubois believed 
it to depend on a laceration of the membranes at a distance from the 
os uteri. Mattei more recently has attributed it to the existence of 
a sac between the chorion and the amnion. It may be that in some 
instances a single discharge of fluid may come from one of the two 
last-mentioned causes. But if it be continuous or repeated, another 
source must be sought for. Hegar 1 maintains that it is the result of 
abundant secretion from the glands of the mucous membrane, which 
accumulates between the decidua and chorion, and escapes through 
the os uteri. If this occur the decidua is probably in an hypertro- 
phied and otherwise morbid state. Hydrorrhoea is chiefly of interest 
from the error of diagnosis it is likely to give rise to ; for, on being- 
summoned to a case in which watery discharge has occurred for the 
first time, we are naturally apt to suppose that the membranes have 
ruptured, and that labor is imminent. Nor is there any very certain 
means of deciding if this be so. In hydrorrhoea, we find that pains 



1 Monat. f. Geburt., 1863. 



PATHOLOGY OF THE DECIDUA AND OVUM. 



215 



Fig. 84. 



are absent, the os uteri unopened, and ballottement may be made 
out. Even if the membranes be ruptured, there will be no indica- 
tion for interference unless labor has actually commenced ; and the 
repetition of the discharge, and the continuance of the pregnane}^, 
will soon clear up the diagnosis. Hydrorrhcea, although apt to 
alarm the patient, need not give rise to any anxiety. The pregnancy 
generally progresses favorably to the full period ; although, in excep- 
tional cases, premature labor may supervene JSTo treatment is neces- 
sary, nor is there any that could have the least effect in controlling 
the discharge. 

Pathology of the Chorion. — The only important disease of the 
chorion, with which we are acquainted, is the well-known condition 
which is variously described as uterine hydatids, cystic disease of the 
ovum, hydatiform degeneration of the chorion, or vesicular mole. The 
name of uterine hydatids was long given to it on the supposition that 
the grapelike vesicles, which characterize the disease, were true hyda- 
tids, similar to those which develop in the liver and other structures. 
This idea has long been exploded, and it is now known as a certainty 
that the disease originates in the villi of the chorion. The precise 
mode and the causes of its production, are, however, not yet satisfac- 
torily settled. The disease is character- 
ized by the existence in the cavity of the 
uterus of a large number of translucent 
vesicles,, containing a clear limpid fluid, 
which has been found on analysis to bear 
close resemblance to the liquor amnii. 
These small bladder-like bodies, which 
vary in size from that of a millet-seed to 
an acorn, are often described as resem- 
bling a bunch of grapes or currants. On 
more minute examination, they are found 
not to be each attached to independent 
pedicles, as is the case in a bunch of 
grapes, bat some of them grow from 
other vesicles, while others have distinct 
pedicles attached to the chorion, the pedi- 
cles themselves sometimes being dis- 
tended by fluid (Fig. 84). This peculiar 
arrangement of the vesicles is explained 
by their mode of growth. 

Causes of Cystic Degeneration. — There 
has been considerable discussion as to 
the etiology of this disease. By some it 
is supposed always to follow death of 
the foetus ; and the whole developmental 
energy being expended on the chorion, which retains its attachment 
to the decidua, the result is its abnormal growth and cystic degenera- 
tion. This is the view maintained by Gierse and Graily Hewitt, and 
it is favored by the undoubted fact that in almost all cases the foetus 
has entirely disappeared ; and by the occasional occurrence of cases 




Hydatiform Degeneration of tht 
Chorion. 



216 PREGNANCY. 

of twin conceptions in which one chorion has degenerated, the other 
remaining healthy until term. On the other hand, it is maintained 
that the starting-point is connected with the maternal organism. 
Virchow thinks it originates in a morbid state of the decidua ; while 
others have attributed it to some blood dyscrasia on the part of the 
mother, such as syphilis. There are many reasons for believing that 
canses of this nature may originate the affection. Th us it is often found 
to occur more than once in the same person ; and alterations of a simi- 
lar kind, although limited in extent, are not unfrequentiy found in 
connection with the placenta and membranes of living children. On 
this theory the death of the foetus is secondary, the consequence of 
impaired nutrition from the morbid state of the chorion. The prob- 
ability is that both views may be right, the disease sometim.es fol- 
lowing the death of the embryo, and at others being the result of 
obscure maternal causes. 

Pathology. — The degeneration of the chorion villi generally com- 
mences at an early period of pregnancy, before the placenta has com- 
menced to form. In that case the entire superficies of the chorion 
becomes affected. The disease, however, may not begin until after 
the greater part of the chorion villi has atrophied, and then it is lim- 
ited to the placenta. The epithelium of the villi appears to be the 
part first affected, and the whole interior of the diseased villus 
becomes filled with cells. The connective tissue of the villus under- 
goes a remarkable proliferation, and collects in masses at individual 
spots, the remainder of the villus being unaffected. By the growth 
of these elements the villus becomes distended, and many of the cells 
liquefy, the intercellular fluid, thus produced, widely separating the 
connective tissue, so as to form a network in the interior of the vil- 
lus. 1 Thus are formed the peculiar grapelike bodies which charac- 
terize the disease. When once the degeneration has commenced, the 
diseased tissue has a remarkable power of increase, so that it some- 
times forms a mass as large as a child's head, and several pounds in 
weight. 

The nutrition of the altered chorion is maintained by its connec- 
tion with the decidua, which is also generally diseased and hypertro- 
phied. Sometimes the adhesion of the mass to the uterine walls is 
very firm, and may interfere with its expulsion ; while, in a few rare 
cases, it has been found that the villi have forced their way into the 
substance of the uterus, chiefly through the uterine sinuses, and thus 
caused atrophy and thinning of its muscular structure. Cases of 
this kind are related by Volkmann, Waldeyer, 2 and Barnes, and it is 
obvious that the intimate adhesion thus effected must seriously add 
to the gravity of the prognosis. 

Medico-legal Questions. — Taking this view of the etiology of this 
disease, it is obvious that it is essentially connected with pregnancy, 
and that there is no valid ground for maintaining, as has sometimes 
been done, that it may occur independently of conception. It is just 

1 Braxton Hicks, Guy's Hospital Reports, vol. ii. Third Series, p. 183. 

2 Virchow's Archiv, vol. xliv. p. 88. 



PATHOLOGY OF THE DECIDTJA AND OVUM. 217 

possible, however, that true entozoa may form in the substance of 
the uterus, which being expelled per vaginam, might be taken for 
the results of cystic disease, and thus give rise to groundless suspi- 
cions as to the patient's chastity. Hewitt has related one case in 
which true hydatids, originally formed in the liver, had extended to 
the peritoneum, and were about to burst through the vagina at the 
time of death. This occurred in an unmarried woman. One or two 
other examples of true hydatids forming in the substance of the ute- 
rus are also recorded. A very interesting case is also related by 
Hewitt, 1 in which undoubted acephalocysts were expelled from the 
uterus of a patient who ultimately recovered. A careful examina- 
tion of the cyst and its contents would show their true nature, as the 
echinococci heads, with their characteristic hooklets, would be dis- 
coverable by the microscope. 

It is also possible that unfounded suspicions might arise from the 
fact of a patient expelling a mass of hydatids long after impregnation. 
In the case of a widow, or woman living apart from her husband, 
serious mistakes might thus be made. This has been specially 
pointed out by McClintock, 2 who says, "Hydatids maybe retained in 
utero for many months or years, or a portion only may be expelled, 
and the residue may throw out a fresh crop of vesicles, to be dis- 
charged on a future occasion." 

Symptoms and Progress of the Disease. — The symptoms of cystic 
disease of the ovum are by no means well marked. At first there is 
nothing to point to the existence of any morbid condition, but as 
pregnancy advances its ordinary course is interfered with. There is 
more general disturbance of the health than there ought to be, and 
the reflex irritations, such as vomiting, may be unusually developed. 
The first physical sign remarked is rapid increase of the uterine 
tumor, which soon does not correspond in size to the supposed period 
of pregnancy. Thus, at the third month, the uterus may be found 
to reach up to, or beyond, the umbilicus. About this time there 
generally are more or less profuse watery and sanguineous dis- 
charges, which have been described as resembling currant juice. 
They no doubt depend on the breaking down and expulsion of the 
cysts, caused by painless uterine contractions. They are sometimes 
excessive in amount, recur with great frequency, and often reduce 
the patient extremely. Portions of cysts may now generally be found 
mingled with the discharge, and sometimes large masses of them are 
expelled from time to time. Indeed, the discovery of portions of 
cysts is the only certain diagnostic sign. Vaginal examination, 
before the os has dilated, will give no information, except the absence 
of ballottement. An unusual hardness or density of the uterus- 
described by Leishman, who attributes much importance to it, as "a 
peculiar doughy, boggy feeling"— has been pointed out by several 
writers. The contour of the uterine tumor, moreover, is often irregu- 
lar. In addition, we, of course, fail to discover the usual ausculta- 
tory signs of pregnancy. All this may aid in diagnosis, but nothing, 

1 Obstet. Trans., vol. xii. 2 McClintoek's Diseases of Women, p. 398. 

15 



218 PREGNANCY. 

except the presence of cysts in the watery bloody discharge, will 
enable ns to pronounce with certainty as to the nature of the disease. 

Treatment. — As soon as the diagnosis is established, the indications 
for treatment are obvious. The sooner the uterus is cleared of its 
contents the better. Ergot may be given with advantage to favor 
uterine contraction, and the expulsion of the diseased ovum. Should 
this fail, more especially if the hemorrhage be great, the fingers, or 
the Avhole hand, must be introduced into the uterus, and as much as 
possible of the mass removed. As the os is likely to be closed, its 
preliminary dilatation by sponge or laminaria tents, or by a Barnes's 
bag, if it be already opened to some extent, will in most cases be 
required. If chloroform be then administered, the remaining steps 
of the operation will be easy. On account of the occasional firm 
adhesion of the cystic mass to the uterus, too energetic attempts at 
complete separation should be avoided. Any severe hemorrhage 
after the operation can be controlled by swabbing out the uterine 
cavity with the per chloride of iron solution. 

Under the name of Myxoma fibrosum, a more rare degeneration of 
the chorion has been described by Yirchow and Hildebrandt, 1 char- 
acterized, not by vesicular, but fibroid degeneration of the connective 
tissue of the chorion. This is, however, too little understood to 
require further observation. 

Pathology of the Placenta. — The pathology of the placenta has of 
late years attracted much attention, and it has an important practical 
bearing in consequence of its effects on the child. 

Placentas vary considerably in shape. They may be crescentic, or 
spread over a considerable surface, in consequence of the chorion 
villi entering into communication with a larger portion of the de- 
cidua than usual [Placenta membranacea). Such forms, however, 
are merely of scientific interest. The only anomaly of shape of any 
practical importance is the formation of what have been called pla- 
centae succenturise. These consist of one or more separate masses of 
placental tissue, produced by the development of isolated patches of 
chorion villi. Hohl believes that they always form exactly at the 
junction of the anterior and posterior walls of the uterus, which in 
early pregnancy is a mere line. As the uterus expands, the portions 
of placenta, on each side of this, become separated from each other. 
They are only of consequence from the possibility of their remain- 
ing unnoticed in the uterus after delivery, and giving rise to second- 
ary post-partum Hemorrhage. The rare form of double placenta 
with a single cord, figured in the accompanying woodcut (Fig. 85), 
was probably formed in this way, and the supplementary portion, in 
such a case, might readily escape notice. 

The placenta may also vary in dimensions. Sometimes it is of 
excessive size, generally when the child is unusually big ; but not 
infrequently in connection with hydramnios, the child being dead 
and shrivelled. In other cases it is remarkably small, or at least 
appears to be so. If the child be healthy, this is probably of no 

1 Monat. f. Geburt, May, 1865. 



PATHOLOGY OF THE DECIDUA AND OVUM 



219 



pathological importance, as its smallness may be more apparent than 
real, depending on its vessels not being distended with blood. When 
true atrophy of the placenta exists, the vitality of the foetus may be 
seriously interfered with. This condition may depend either on a 
diseased state of the chorion villi, or of the decidua in which they 
are implanted. 1 The latter is the more common of the two ; and it 
generally consists in hyperplasia of the connective tissue of the de- 
cidua, which presses on the villi and vessels, and gives rise to gen- 
eral or local atrophy. This change is similar in its nature to that 
observed in cirrhosis of the liver, and certain forms of Bright's dis- 
ease. It has generally been ascribed to inflammatory changes, and, 
under the name of placentitis, has been described by many authors, 



Fig. 




Double Placenta, with single cord 



and has been considered to be a common disease. To it are attributed 
many of the morbid alterations which are commonly observed in 
placentae, such as hepatization, circumscribed purulent deposits, and 
adhesions to the uterine walls. Many modern pathologists have 
doubted whether these changes are in any proper sense inflammatory. 
Whittaker observes on this point : " The disposition to reject pla- 
centitis altogether increases in modern times. Indeed, it is impos- 
sible to conceive of inflammation on the modern theory (Cohnheim) 
of that process, since there are no capillaries, in the maternal portion 



1 Whittaker, Amer. Journ. of Obst.. vol. iii., p. 229. 



220 



PREGNANCY 



at least, through whose walls a 'migration' might occur, and there 
are no nerves to regulate the contractility of the vessel- walls in the 
entire structure." Kobin thus explains the various pathological 
changes above alluded to: "What has been taken for inflammation 
of the placenta is nothing else than a condition of transformation of 
blood clots at various periods. What has been regarded as pus is 
only fibrine in the course of disorganization, and in those cases 
where true pus has been found the pus did not come from the pla- 

Fig. 86. 




fee/ 

Fatty Degeneration of the Placenta. 



centa, but from an inflammation of the tissue of the uterine vessels 
and an accidental deposition in the tissue of the placenta." The 
extravasations of blood here alluded to are of very common occur- 
rence, and they are found in all parts of the organ ; in its substance, 
on its decidual surface, or immediately below the amnion, where 
they serve as points of origin for the cysts that are there often 
observed. The fibrine thus deposited undergoes retrograde meta- 
morphosis as iii other parts of the body ; it becomes decolorized, it 
undergoes fatty degeneration or becomes changed into calcareous 
masses ; and in this way, it is supposed, may be explained the vari- 
ous pathological changes which are so commonly observed. The 
amount of retrograde metamorphosis, and the precise appearance 
presented will, of course, depend on the time that has elapsed since 
the blood extravasations took place. 

Fatty degeneration of the placenta, and its influence on the nutri- 



PATHOLOGY OF THE DECIDUA AND OVUM 



221 



tion of the foetus, have been specially studied iu this country by 
Barnes and Druitt. Yellowish masses of varying size are very 
commonly met with in placentae, and these are found to consist, in 
great part, of molecular • fat, mixed with a fine network of fibrous 
tissue. The true fatty degeneration, however, specially affects the 
chorion villi (Fig. 86). On microscopic examination they are found 
to be altered and misshaped in their contour, and to be loaded with 
fine granular fat-globules. Similar changes are observed in the cells 
of the decidua. The influence on the foetus will, of course, depend 
on the extent to which the functions of the villi are interfered with. 
The probable cause of this degeneration is, no doubt, some obscure 
alteration in the nutrition of the tissue, depending on the state of the 
mother's health. Barnes believes that syphilis has much influence 
in its production. Druitt has pointed out that some amount of fatty 
degeneration is always present in a mature placenta, and is probably 
connected with the physiological separation of the organ ; and Groodell 
has more recently suggested that an unusual amount of this change 
may be merely an anticipation of the natural termination of the life 
of the placenta. 1 

Other morbid states of the placenta, of greater rarity, are occasionally 
met with, as an oedematous infiltration of its tissue, always occurring, 
according to Lange, in cases of hydramnios ; pigmentary and calca- 
reous deposits; and tumors of various kinds : but these require only 
a passing mention. 

Pathology of the Umbilical Cord. — The umbilical cord may be of 
excessive length, varying from 18 to 20 inches, which is its average 
measurement, up to 50 or 60 inches, and 
a case is recorded in which it even reached 
the extraordinary length of 9 feet. If 
unusually long it may be twisted round 
the limbs or neck of the child, and the 
latter position may, in exceptional in- 
stances, prove injurious during labor. 

Some authors refer cases of spontane- 
ous amputation of foetal limbs in utero 
to constrictions by the umbilical cord, 
but this accident is more probably pro- 
duced by filamentous adnexa of the 
amnion. Knots in the cord are not un- 
common, and they result from the foetus, 
in its movements, passing through a loop 
of the cord (Fig. 87). If there is an 
average amount of Wharton's jelly in 
the cord the vessels are protected from 
pressure, and no bad effects follow. Grery, 
in a recent paper on this subject, 2 at- 
tempts to show that such knots are more 



Fig 




Knots of the Umbilical Cord. 



1 American Journal of Obstetrics, vol. ii. p. 535. 

2 L' Union Medicale, Oct., 1876. 



222 PREGNANCY. 

important than is generally believed, and relates two cases in which 
he believes them to have caused the death of the foetus. 

Extreme torsion of the cord, an exaggeration of the spiral twists 
generally observed, may prove injurious, and even fatal, to the child 
by obstructing the circulation in the vessels. Spaeth mentions three 
cases in which this caused the death of the foetus, the cord being 
twisted until it was reduced to the thickness of a thread. 

Anomalies in the distribution of the vessels of the cord are of 
common occurrence. The cord may be attached to the edge, instead 
of to the centre, of the placenta {battledore placenta). It may break 
up into its component parts before reaching the placenta, the vessels 
running through the membranes ; and if, in such a case, traction on 
the cord be made, the separate vessels may lacerate, and the cord 
become detached. There may be two veins and one artery, or only 
one vein and oue artery, or there may be two separate cords to one 
placenta. These, and other anomalies that might be mentioned, are 
of little practical importance. 

The principal pathological condition of the amnion with which we 
are acquainted is that which is associated Avith excessive secretion of 
liquor amnii, and is generally known under the name of hydr amnios. 
Its precise cause is still a matter of doubt. By some it is referred to 
inflammation of the amnion itself; at other times it is apparently 
connected with some morbid state of the decidua, which may be 
found diseased and hypertrophied. The foetus is very often dead 
and shrivelled, and the placenta enlarged and ©edematous. It does 
not necessarily follow, however, that hydramnios causes the death of 
the child. Out of 33 cases McClintock found that 9 children were 
born dead ; x and of the 19 born alive, 10 died within a few hours, the 
remainder survived. There does not appear to be any marked rela- 
tion between the state of the mother's health and the occurrence of 
this disease ; and it is certainly not necessarily present when the 
mother is suffering from dropsical effusions in other parts of the 
body. The theory that the disease is of purely local origin is favored 
by the fact, that when hydramnios occurs in twin pregnancy, one 
ovum only is generally affected. Its effects, as regards the mother, 
are chiefly mechanical. It rarely begins to show itself before the 
fifth or sixth month of pregnancy, but, when once it has commenced, 
it rapidly produces a feeling of discomfort and enlargement, alto- 
gether beyond that which should exist at the period of pregnancy 
which has been reached. In advanced stages the distress produced 
is often very great, the enlarged uterus pressing upon the diaphragm, 
and producing much embarrassment of respiration. Premature 
expulsion of the foetus very often supervenes. Four out of McClin- 
tock's patients died after labor, showing that the maternal mortality 
is high, a result which he refers to the debilitated state of the women 
who were the subjects of the disease. 

Diagnosis. — The diagnosis is not, as a rule, difficult. It has to be 
distinguished from ascitic distension of the abdomen, and from en- 

1 Diseases of Women, p. 383. 



PATHOLOGY OF THE DECIDUA AND OVUM. 223 

largement of the uterus from twin pregnancy. The former will be 
recognized by the superficial position of the fluid ; the difficulty of 
feeling the contour of the uterus, which is obscured by the surround- 
ing fluid ; and by the coexistence of dropsical effusions in other 
parts of the body. The latter may be difficult, and even impossible, 
to diagnose from it : generally, however, in hydramnois the uterine 
tumor is more distinctly tense or fluctuating; the foetal limbs cannot 
be felt on palpation ; and the lower segment of the uterus, as felt per 
vaginam, is unusually distended, the presenting part not being ap- 
preciable. 

Its effect on Labor. — During labor an excessive amount of liquor 
amnii is often a cause of deficient uterine action and delay, the pains 
being feeble and ineffective. This, of course, tells chiefly in the first 
stage, which is often much prolonged, unless the membranes are 
punctured early, and the superabundant fluid allowed to escape. 

Treatment. — Xo treatment is known to have any effect on the 
disease. If the discomfort and distension are verj T great, it may be 
absolutely necessary to puncture the membranes, and allow the water 
to escape. This inevitably brings on labor. If the pregnancy be 
not sufficiently advanced to give hope for the birth of a living child, 
we would not, of course, resort to this expedient unless the mother's 
health was seriously imperilled. It is possible that in such cases the 
patient might be relieved by inserting the minute needle of an aspi- 
rator through the os, and removing a certain quantity of the liquor 
amnii by aspiration, without inducing the labor. I have never had 
an opportunity of trying this expedient, but it seems a possibility. 

Deficiency of Liquor Amnii. — A defective amount of liquor amnii 
is said to favor certain malformations, by allowing the uterus to 
compress the foetus unduly. It certainly occasionally gives rise to 
adhesion between the foetus and the membranes, and to the formation 
of amniotic bands which are capable of producing certain foetal de- 
formities (p. 227). 

Appearance of the Liquor Amnii. — The liquor amnii itself varies 
much in appearance. It is sometimes thick and treacly, instead of 
limpid, and it may be offensive in odor. The cause of these varia- 
tions is not well understood. 

Pathology of the Foetus. — There is abundant evidence that the foetus 
in utero is subject to many diseases, some of which cause its death, 
and others leave distinct traces of their existence, although not 
proving fatal. The subject is of great importance, and is well worthy 
of study. There is still much to be done in this direction, which 
may yet lead to important practical results. I can, however, do little 
more than enumerate some of the principal affections which have 
been observed. 

Blood Diseases transmitted through the Mother. Smallpox. — It is a 
well-established fact that the various eruptive fevers, from which 
the mother may suffer, may be communicated to the foetus in utero. 
When the mother is attacked with confluent smallpox, she almost 
always aborts, but not necessarily so when it is discrete or modified. 
In such cases it has often happened that the foetus has been born 



224 PKEGNANCY. 

with evident marks of smallpox. Cases are on record which, prove 
that the foetus was attacked subsequently to the mother. Thus a 
mother attacked with smallpox has miscarried, and has given birth 
to a living child showing no trace of the disease, which, however, 
showed itself in two or three days; proving that it had been con- 
tracted, and had ran through its usual period of incubation, when 
the foetus was still in utero. It does not follow, however, that the 
foetus is aifected, as Serres has collected 22 cases in which women, 
suffering from smallpox, gave birth to children who had not con- 
tracted the disease. It has been supposed that, in such cases, the 
child is protected from small-pox, though it has shown no symptom 
of having had the disease. Tarnier, however, cites two instances in 
which such children had smallpox two years after birth. Madge 
and Simpson record cases in which vaccination performed on the 
mother daring pregnancy protected the foetus, on whom all subse- 
quent attempts at vaccination failed. There is evidence also to 
prove that the disease may be transmitted to the foetus through a 
mother, who is herself unsusceptible of contagion; the child having 
been covered with smallpox eruption, the mother being quite free 
from it. It is probable, that the same facts which have been ob- 
served with regard to smallpox, hold true with reference to other 
zymotic diseases, such as scarlet fever and measles, although there is 
not sufficient evidence to justify a positive assertion to that effect. 

Measles and Scarlet Fever. — 'Amongst other maternal diseases, mala- 
rious and lead poisoning are known to affect the foetus in utero. Dr. 
Stokes relates cases in which the mother suffered from tertian ague, 
the child having also attacks, as evidenced by its convulsive move- 
ments, appreciable by the mother, which took place at the regular 
intervals, but at a different time from the mother's paroxysms. In 
other cases the febrile paroxysm comes on at the same time in the 
foetas as in the mother; and the fact has been verified by the observa- 
tion that the paroxysms continued to recur simultaneously after 
delivery. The foetus has also been born with distinct malarious 
enlargement of the spleen. From the frequency with which largely 
hypertrophied spleens are seen in mere infants in malarious districts, 
I imagine that the intra-uterine disease must be common. I have 
frequently observed this fact in India, although, of course, without 
any possibility of ascertaining if the mothers had suffered from inter- 
mittent fever during pregnancy. Lead-poisoning is also known to 
have a most prejudicial effect on the foetus, and frequently to lead to 
abortion. M. Paul has collected 81 cases, 1 in which it caused the 
death of the foetus, in some not until after birth; and occasionally it 
seems to have affected the foetus even when the mother escaped. 

Syphilis. — Of all blood dyscrasias transmitted to the foetus, the 
most important is sj^pliilis. Its influence in producing repeated 
abortion has been elsewhere described. It may unquestionably be 
transmitted to the foetus without producing abortion, and at term 
the mother may be either delivered of a living child, bearing evi- 

1 Arch. Gen. tie Med., I860. 



PATHOLOGY OF THE DECIDUA AND OVUM. 225 

dent traces of the disease ; of a dead child similarly affected ; or of 
an apparently healthy child in whom the disease develops itself 
after a lapse of a month or two. These varying effects probabl} r de- 
pend on the intensity of the poison. The disease is, no doubt, gen- 
erally transmitted through the mother, and if she be affected at the 
time of conception, the infection of the feet us seems certain. If, 
however, she contracts the disease at an advanced period of preg- 
nancy the child may entirely escape. Kicord even believes that 
syphilis, contracted after the six months of pregnancy, never affects 
the child. The father alone may transmit the disease to the ovum ; 
and Hutchinson has recorded cases to show that the mother may be- 
come secondarily affected through the diseased foetus. The evi- 
dences of syphilitic taint in a living or dead child are sufficiently 
characteristic. The child is generally puny and ill-developed. An 
eruption of pemphigus is common, either fully developed bullae, or 
their early stage, when they form circular copper-colored patches. 
This eruption is always most marked on the hands and feet, and a 
child born with such an eruption may be certainly considered sphi- 
litic. On post-mortem examination the most usual signs are small 
patches of suppuration in the thymus, similar localized suppurations 
in the tissues of the lungs, indurated yellowish patches in the liver, 
and peritonitis, the importance of which in causing the death of 
syphilitic children has been specially dwelt on by Simpson. 1 

Inflammatory Diseases. — The most important of the inflammatory 
diseases affecting the foetus is peritonitis. Simpson has shown that 
traces of it are very frequently met with, and that it is not always 
syphilitic. Sometimes it has been observed when the mother has 
been in bad health during pregnancy, and at others it seems to have 
resulted from some morbid condition of the foetal viscera. Pleurisy, 
with effusion, is another inflammatory affection which has been 
noticed. 

Dropsies. — The dropsical affections most generally met with are 
ascites and hydrocephalus, which may both have the effect of im- 
peding delivery. Of these hydrocephalus is the more common, and 
may give rise to much difficulty in labor. Its causes are uncertain 
but it probably depends on some altered state of the mother's health, 
as it is apt to recur in several successive pregnancies, and is not in- 
frequently associated with an imperfectly developed vertebral column 
and spina bifida. The fluid collects in the ventricles, which it 
greatly distends, and these then produce expansion and thinning of 
the crauium, the bones of which are widely separated from each 
other at the sutures, which are prominent and fluctuating. In a 
few cases internal hydrocephalus may be complicated, and the diag- 
nosis in labor consequently obscured, by the coexistence of what 
has been called " external hydrocephalus." This consists of a collec- 
tion of fluid between the skull and the scalp, which may be either 
formed there originally, or may collect from a rupture of one of the 
sutures or fontanelles during labor, through which the intra-cranial 
fluid escapes. 

1 Obst. Works, vol. i. p. 117. 



226 



PREGNANCY. 



Ascites is generally associated with hydramnios, and sometimes 
with hydro-thorax, or other dropsical effusions. Tt is a rare affec- 
tion, and, according to Depaul, 1 extreme distension of the bladder is 
noj; infrequently mistaken for it. 

Tumors of different kinds may be met with in various parts of the 
child's body, which sometimes grow to a great size and impede de- 
livery. Tarnier records cases of meningocele larger than a child's 
head, and large cj^stic growths have been observed attached to the 
nates, pectoral region, or other parts of the body. Cancerous tumors 
of considerable size, either external, or of the viscera, have also been 
met with. Other foetal tumors may be produced by congenital de- 
formities, such as projection of the liver or other abdominal viscera 
through a deficiency of the abdominal wall ; or spina bifida, from 
imperfectly developed vertebrae. The amount of dystocia produced 
by such causes will, of course, vary much in proportion to the size, 
consistency, and accessibility of the tumor. 

Wounds and Injuries of the Foetus. — Accidents of serious gravity 
to the foetus may happen from violence, to which the mother has 
been subjected, such as falls or blows, without necessarily interfering 
with gestation. Many curious examples of this kind are on record. 
Thus a child has been born presenting a severe lacerated wound, ex- 
tending the whole length of the spine, Avhere both the skin and the 
muscles had been torn, and which seems to have resulted from the 
mother having fallen in the last month of pregnancy. Similar 
lacerations and contusions have been observed in other parts of the 
body, the wounds being in various stages of cicatrization, corre- 
sponding to the lapse of time since the acci- 
dent had occurred. Intra-uterine fractures 
are not rare, apparently arising from similar 
causes. In some of these cases the broken 
ends of the bones had united, but, from want 
of accurate apposition, at an acute angle, so 
as to give rise to much subsequent de- 
formity. Chaussier records two cases in 
which there were many fractures in the 
same child, in one 113, and in another 42, 
which were in different stages of repair. He 
attributes this curious occurrence to some 
congenital defect in the nutrition of the 
bones, possibly allied to mollities ossium. 2 

Intra-uterine amputations of foetal limbs 
have not infrequently been observed. 
Children are occasionally born with one ex- 
tremity more or less completely absent, and 
cases are known in which the whole four 
extremities were wanting (Fig. 88.) The 
mode in which these malformations are produced has given rise to 
much discussion. At one time it was supposed that the deficiency 



Fig 




Intra-uterine Amputation of both 
Arms and Le<?s. 



Tarnier' s Cazeaux, p. 855. 



Gazette Hebdom., 1860. 



PATHOLOGY OF THE DECIDUA AND OVUM. 227 

of the limb was clue to gangrene of the extremity, and subsequent 
separation of the sphacelated parts. Keuss, who has studied the 
whole subject very minutely, 1 considers gangrene in the unruptured 
ovum to be an impossibility, for that change cannot occur unless 
there is access of oxygen, and when portions of the separated ex- 
tremity are found in utero, as is often the case, they show evidences 
of maceration, but not of decomposition. The general belief is that 
these intra-uterine amputations depend on constriction of the limb 
by folds or bands of the amnion — most often met with when the 
liquor amnii is deficient in quantity — which obstruct the circulation, 
and thus give rise to atrophy of the part below the constriction. It 
has been supposed that the umbilical cord might, by encircling the 
limb, produce a like result. It appears doubtful, however, whether 
this cause is sufficient to produce complete separation of the limb, as 
any great amount of constriction would interfere with the circulation 
through the cord. Sometimes, when intra-uterine amputation occurs, 
the separated portion of the limb is found lying loose in the amniotic 
cavit} r , and is expelled after the child. Cases of this kind have been 
recorded by Martin, Chaussier, and TVatkinson. More often no trace 
of the separated extremity can be found. The explanation probably 
depends upon the period of utero -gestation at which amputation took 
place. If it occurred at a very early period of pregnancy, before the 
third month, the detached portion would be minute and soft, and 
would easily disappear by solution. If at a later period, this could 
hardly happen, and the detached portion would remain in utero. In 
cases of the latter kind cicatrization of the stump has often been ob- 
served to be incomplete. Simpson pointed out the occasional exist- 
ence of rudimentary fingers or toes on the stump of an amputated 
limb, such as are seen on the thighs in Fig. 88. These he attributed 
to an abortive reproduction of the separated extremity, analogous to 
what is observed in some of the lower animals. This explanation 
has been contested with much show of reason. Martin believes that 
the reproduction is only apparent, and that the rudimentary ex- 
tremities are, in reality, instances of arrested development. The 
constricting agents interfered with the circulation sufficiently to 
arrest the growth of the limb below the site of constriction, but not 
sufficiently to effect complete separation. If constriction occurred 
at a very early stage of development an appearance similar to that 
observed by Simpson would be produced. It does not follow, how- 
ever, that all cases of absence of limbs depend on intra-uterine ampu- 
tations. In some cases they would appear to be the result of a sponta- 
neous arrest of development, or of congenital monstrosity. Mr. Scott 2 
relates a case in which a. distinct hereditary tendency was evident, 
and here the deformity certainly could not have resulted from the 
constriction of amniotic bands. In this family the grandfather had 
both forearms wanting, with rudimentary fingers attached ; the next 
generation escaped ; but the grandchild had a deformity precisely 
similar to the grandfather. 

1 Scanzoni's Beitr'age, 1869 2 Obstet. Trans., vol. xiii. p. 94. 



228 PREGNANCY. 

Death of Foetus. — When, from any cause, the foetus has died during 
pregnancy, it may either be soon expelled, or it may be retained in 
utero for a longer or shorter time, or even to the fall period. The 
changes observed in such foetuses vary considerably according to the 
age of the foetus at the time of death, or the time that it has been 
retained in utero. If it die at an early period, when the tissues are 
very soft, it may entirely dissolve in the liquor amnii, and no trace 
of it may be found when the membranes are expelled. Or it may 
shrivel or mummify; and if this happen in a twin pregnancy, as 
sometimes occurs, the growing foetus may compress and flatten the 
dead one against the uterine wall. 

Appearance. — At a later period of pregnancy a dead foetus under- 
goes changes ascribed to putrefaction, but which produce appearances 
different from those of decomposition in animal textures exposed to 
the atmosphere. There is no offensive smell, as in ordinary decay. 
The tissues are all softened and flaccid. The more manifest changes 
are in the skin, the epidermis of which is separated from the cutis 
vera, which has a deep reddish color. This is especially apparent on 
the abdomen, which is flaccid, and hollow in the centre. The internal 
organs are much altered. The brain is diffluent and pulpy, and the 
cranial bones loose within the scalp. The structures of the muscles 
and viscera are in various stages of transformation, many having 
undergone fatty changes, and containing crystals of margarin and 
cholesterin. The extent to which these changes occur depends, to a 
great extent, on the length of time the foetus has been dead, but they 
do not admit of our estimating with any degree of accuracy what that 
time has been. 

The symptoms and diagnosis of the death of the foetus may here be 
considered. They are, unfortunately, not very reliable. The cessa- 
tion of the foetal movements cannot be depended on, as they are 
frequently unfelt for days or weeks, when the child is alive and well. 
Sometimes the death of the foetus is preceded by its irregular and 
tumultuous movements, and, in women who have been delivered of 
several dead children in succession, this sensation may guide us in 
our diagnosis. This suspicion may be confirmed by auscultation. 
The mere fact that we are unable, at any given time, to hear the 
foetal heart will not justify an opinion that the foetus is dead. If, 
however, the foetal heart has been distinctly heard, and after one or 
two careful examinations, repeated at separate times, it cannot again 
be made out, the probability of the child being dead may be assumed. 
Certain changes in the mother's health have been noted in connection 
with the death of the foetus, such as depression and lowness of spirits, 
a feeling of coldness and weight about the lo,wer parts of the abdomen, 
paleness of the face, a livid circle round the eyes, irregular shiverings 
and feverishness, shrinking of the breasts, .and diminution in the size 
of the abdominal tumor. All these, however, are too indefinite to 
justify a positive diagnosis, and they are not infrequently altogether 
absent. At most t\\Qy can do no more than cause a suspicion as to 
what has happened. 



ABORTION AND PREMATURE LABOR. . 229 



CHAPTER X. 

ABORTION AND PREMATURE LABOR. 

Importance and Frequency of Abortion. — The premature expulsion 
of the foetus is an event of great frequency. The number of foetal 
lives thus lost is enormous. There are few multiparas who have not 
aborted at one time or other of their lives. Hegar estimates that 
about one abortion occurs to every 8 or 10 deliveries at term. White- 
head has calculated that at least 90 per cent, of married women, who 
lived to the change of life, had aborted. The influence of this acci- 
dent on the future health of the mother is also of great importance. 
It rarely, indeed, proves directly fatal, but it often produces great 
debility from the profuse loss of blood accompanying it ; and it is 
one of the most prolific causes of uterine disease in after life, possibly 
because women are apt to be more careless during convalescence than 
after delivery, and the proper involution of the uterus is thus more 
frequently interfered with. 

Definition. — A not uncommon division of the subject is into abor- 
tion, miscarriage, and premature labor, the first name being applied 
to expulsion of the ovum before the end of the fourth month of utero- 
gestation ; miscarriage to expulsion from the end of the fourth to the 
end of the sixth, month ; and premature labor to expulsion from the 
end of the sixth month to the term of pregnancy. This is, however, 
a needless and confusing subdivision, which leads to no practical 
result. It suffices to apply the term abortion or miscarriage indis- 
criminately to all cases in which pregnancy is terminated before the 
foetus has arrived at a viable age, and premature labor to those in 
which there is a possibility of its survival. There is little or no 
hope of a foetus living before the 28th week or seventh lunar month, 
and this period is therefore generally fixed on as the limit between 
premature labor and abortion. The rule is, however, not without 
an occasional, although very rare, exception. Dr. Keiller, of Edin- 
burgh, has recorded an instance in which a foetus was born alive at 
the fourth month, nine days after the mother had experienced the 
sensation of quickening. I myself recently attended a lady who mis- 
carried in the fifth month of pregnancy, the child being born alive, 
and living for three hours. Several cases are on record in which 
after delivery at the sixth month the child survived, and was reared. 
The possibility of the birth of a living child under such circum- 
stances should be recognized, at it may give rise to legal questions 
of importance ; but the exceptions to the ordinary rule are so rare, 
that they need not interfere with the division of the subject usually 
made. 



230 PREGNANCY. 

Abortion is most Common in Multipara. — Multipara abort far more 
frequently than primiparse. This is contrary to the statement in many 
obstetrical works. Thus, Tyler Smith says "there seems to be a 
greater danger of this accident in the first pregnancy." Schroeder, 1 
however, states that 23 multiparas abort to 3 primiparae; and Dr. 
"Whitehead, of Manchester, who has particularly studied the subject, 
believes that abortion is more apt to occur after the third and fourth 
pregnancies, especially when these take place towards the time for 
the cessation of menstruation. 

Liability to a recurrence of Abortion.- — There can be no doubt that 
women who have aborted more than once are peculiarly liable to a 
recurrence of the accident. This can generally be traced to the exist- 
ence of some predisposing cause which persists through several preg- 
nancies, as, for example, a syphilitic taint, a uterine flexion, or a 
morbid state of the lining membrane of the uterus. It is probable 
that in many women a recurrence of the accident induces a habit 
of abortion, or, perhaps it might be more accurate to say, a peculiar 
irritable condition of the uterus, which renders the continuance of 
pregnancy a matter of difficulty, independently of any recognizable 
organic cause. 

Very early Abortions are often Unrecognized. — The frequency of 
abortion varies much at different periods of pregnancy ; and it occurs 
much more often in the early months, because of the comparatively 
slight connection then existing between the chorion and the decidua. 
At a very early period of pregnancy the ovum is cast off with such 
facility, and is of such minute size, that the fact of abortion having 
occurred passes unrecognized. Very many cases, in which the patient 
goes one or two weeks over her time, and then has what is supposed 
to be merely a more than usually profuse period, are probably in- 
stances of such early miscarriages. Velpeau detected an ovum, of 
about fourteen days, which was not larger than an ordinary pea, and 
it is easy to understand how so small a body should pass unnoticed 
in the blood which escapes along with it. 

Abortions before the Third Month and between the Third and Sixth. 
— Up to the end of the third month, when miscarriage occurs, the 
ovum is generally cast off' en masse, the decidua subsequently coming 
away in shreds, or as an entire membrane. The abortion is then 
comparatively easy. From the third to the sixth month, after the 
placenta is formed, the amnion is, as a rule, first ruptured by the 
uterine contractions, and the foetus is expelled by itself. The pla- 
centa and membranes may then be shed as in ordinary labor. It 
often happens, however, that on account of the firmness of the pla- 
cental adhesion at this period, the secundines are retained for a 
greater or less length of time. This subjects the patient to many 
risks, especially to those of profuse hemorrhage, and of septicemia. 
For this reason, premature termination of the pregnancy is attended 
by" much greater danger to the mother between the third and sixth 
months, than at an earlier or later date. After the sixth month the 

1 Schroeder, Manual of Midwifery, p. 149. 



ABORTION AND PREMATURE LABOR. 231 

course of events is not different from that attending ordinary labor. 
The prognosis to the child is more unfavorable in proportion to the 
distance from the full period of gestation at which premature labor 
takes place. 

Causes. — The causes of abortion may conveniently be subdivided 
into the predisposing and exciting, the latter being often slight, and 
such as would have no effect in inducing uterine contractions in 
women unless associated with one or more of the former class of 
causes. The predisposition to abortion may depend on some condi- 
tion interfering with the vitality of the ovum, or its relation to the 
maternal structures, or on certain conditions directly affecting the 
mother's health. - 

Causes referable to the Foetus. — One of the most common antece- 
dents of abortion is the death of the foetus, which leads to secondary 
changes, and ultimately produces the uterine contractions which end 
in its expulsion. The precise causes of death in any given case cannot 
always be accurately ascertained, as they sometimes depend on con- 
ditions which are traceable to the maternal structures, at others to 
the ovular, or, it may be, to a combination of the two. Nor does it 
by any means follow that the death of the ovum immediately results 
in its expulsion. The mode in which death of the ovum produces 
abortion is not difficult to understand, for it necessarily leads to 

Fig. 89. 




An Apoplectic Ovum, with Blood effused in Masses under the Foetal Surface of the Membrane. 

changes in the relations between the ovular and maternal structures; 
these changes cause hemorrhages — partly external, and partly into 
the membranes — which, in their turn, excite uterine contraction. 
Extravasations of blood may take place in various positions. One 



232 



PREGNANCY 



of the most common is into the decidual cavity, between the decidua 
vera and the decidua reflexa — or between the decidua vera and the' 
uterine walls. If the hemorrhage is only slight, and especially if it 
comes from that portion of the decidua near the internal os, and at 
a distance from the ovum, there need be no material separation, and 
pregnancy may continue. This explains the cases occasionally met 
with, in which there is more or less hemorrhage, without subsequent 
abortion. When the amount of extravasated blood is at all great, 
separation and abortion necessarily result, and the decidua will be 
found on expulsion to have coagula on its surface, and between its 
various layers which are found to project into the cavity of the 
amnion (Fig. 89). In other cases hemorrhage is still more extensive, 
and, after breaking through the decidua reflexa, it forms clots between 
it and the chorion, and even in the cavity of the amnion. Supposing 
expulsion to take place shortly after coagula are deposited among the 
membranes, the blood is little altered, and we have an ordinary 
abortion. If, however, the ovum is retained, the coagulated fibrine, 
and the placenta or membranes, undergo secondary changes, which 
lead to the formation of moles. The so-called fleshy mole (Fig. 90) 

Fig. 90. 




Blighted Ovum, with Fleshy Degeneration of the Membrane. 



is often retained for many weeks or months after the death of the 
foetus, and during this time there may be but little modification of 
the usual symptoms of pregnancy; or, as is frequently the case, it 
gives rise to occasional hemorrhage, until at last uterine contractions 
come on, and it is cast off in the form of a thick fleshy mass, having 
but little resemblance to the ordinaiy products of conception. The 
most probable explanation of its formation is, that when hemorrhage 
originally took place, the effusion of blood was not sufficient to effect 



ABORTION AND PREMATURE LABOR. 233 

the entire separation and expulsion of the ovum. Part of the mem- 
branes, or of the placenta — if that organ had commenced to form — 
retained its organic connection with the uterus, while the foetus 
perished. The attached portion of the placenta or membranes con- 
tinues to be nourished, although abnormally. The foetus generally 
entirely disappears, especially if it has perished at an early period of 
utero-gestation, when it becomes dissolved in the liquor amnii. Or 
it may become macerated, shrivelled, and greatly altered in appear- 
ance. The effused blood becomes decolorized from the absorption 
of the corpuscles; and, according to Scanzoni, fresh vessels are 
developed in the fibrine, which increase the vascular attachment of 
the mole to the uterine walls. The placenta and membranes may 
go on increasing in thickness, until they form a mass of considerable 
size. Careful microscopic examination will almost always enable us 
to discover the villi of the chorion, altered in appearance, often loaded 
with granular fatty molecules, but sufficiently distinct to be readily 
recognizable. 

Causes depending on the Maternal State. — Important as are the 
causes of abortion arising from some morbid condition of the ovum, 
they are not more so than those which depend on the maternal state, 
and it is to be observed that the former are often indirect causes, 
produced by primary maternal changes. Many of these maternal 
causes act by causing hyperemia of the uterus, which leads to ex- 
travasation of blood. Thus abortion is apt to occur in women who 
lead unhealthy lives, such as those who occupy over-heated and ill- 
ventilated rooms, or indulge to excess in the fatigues and pleasures 
of society, in the use of alcoholic drinks, and the like. Over-frequent 
coitus has been, for the same reason, observed to produce a remark- 
able tendency to abortion, and Parent-Duchatelet has noted that it 
is of very frequent occurrence amongst women of loose life. Many 
diseases strongly predispose to it, such as fevers, zymotic diseases 
of all kinds, measles, scarlet fever, smallpox ; and diseases of the 
respiratory organs, such as bronchitis and pneumonia. Syphilis is 
well known to be one of the most frequent causes, and one that is 
likely to act in successive pregnancies. It may act so that the preg- 
nancy is brought to a premature termination, time after time, until 
the constitutional disease is eradicated by appropriate treatment. 
It acts in some cases through the influence of the father in producing 
a diseased ovum ; and it is the only cause which can with certainty 
be traced to the state of the father's health. Many other morbid 
conditions of the blood also dispose to abortion. It has been observed 
to be a frequent result of lead-poisoning ; also of the presence of 
noxious gases in the atmosphere, such as an excess of carbonic acid. 

Causes acting through the Nervous System. — Many causes act 
through the nervous system, such as fright, anxiety, sudden shock, 
and the like. Thus there are numerous instances on record in which 
women aborted suddenly after the receipt of some bad news, and it 
is said to have been of frequent occurrence in women immediately 
before execution. The influence of irritations propagated through 
the nervous system from a distance, tending to produce uterine con- 
16 



234 PREGNANCY. 

traction and abortion throngh the agency of reflex action, has been 
specialty dwelt upon by Tyler Smith. Thus he points out that abor- 
tion not unfrequently occurs from the irritation of constant suckling, 
in women who become pregnant during lactation. The effect of suck- 
ling in producing uterine contraction is, indeed, well known, and the 
application of the child to the breast, for this purpose, has long been 
recognized as a method of treatment in post-partum hemorrhage. 
The irritation of the trifacial in severe toothache ; of the renal nerves 
in cases of gravel, in albuminuria, etc. ; of the intestinal nerves in 
excessive vomiting, in diarrhoea, obstinate constipation, ascarides, 
etc., all act in the same way. We may, perhaps, also explain, by 
this hypothesis, the fact, that women are more apt to abort at what 
would have been the menstrual epoch, than at other times, as the 
ovarian nerves may then be subject to undue excitement. It is prob- 
able, however, that there may be also at these times more or less 
active congestion of the decidua, which may predispose to laceration 
of its capillaries and blood extravasation. Such congestion exists in 
those exceptional cases in which menstruation continues for one or 
more periods after conception, the blood probably escaping from the 
space between the decidua vera and reflexa ; and, therefore, there is 
no reason to question its also happening even when such abnormal 
menstruation is not present. 

Physical Causes.- — Certain physical causes may produce abortion 
by separating the ovum. Thus it may follow a fall, a blow, or other 
accidents of a trivial character. On the other hand, women may be 
subjected to injuries of the severest kind without aborting. The 
probability, therefore, is that these apparently trivial causes only 
operate in women who, for some other reason, are predisposed to the 
accident. This is borne out by the fact — which is well known in 
these days, when the artificial production of abortion is, unhappily, 
far from a very rare event — that it is by no means easy to destroy 
the vitality of the foetus. I myself know of a case, in which the 
uterine sound was passed several times into a pregnant uterus with- 
out producing abortion, the pregnancy proceeding to term. Oldham 
has related a similar case in which he in vain attempted to induce 
abortion by the sound in a case of contracted pelvis ; and Duncan 
has mentioned an instance in which an intra-uterine stem pessary 
was unwittingly introduced, and worn for some time by a pregnant 
woman, without any bad effect. The fact that pregnancy is with 
difficulty interfered with when there is a healthy relation between 
the ovum and the uterus, no doubt, explains the disastrous effects of 
criminal abortion, which have been especially insisted on by many 
of our American brethren. 

Causes depending on Morbid States of the Uterus. — Morbid states of 
the uterus have an important influence in the production of abortion. 
Any condition which mechanically interferes with the proper develop- 
ment of the uterus is apt to operate in this way. Amongst these 
may be mentioned fibroid tumors ; the presence of old peritoneal 
adhesions, rendering the womb a more or less fixed organ ; but, 
above all, flexion and displacement of the uterus. Retroflexion of 



ABORTION AND PREMATURE LABOR. 235 

the uterus is, unquestionably, one of the most frequent factors in its 
production, not only on account of the irritation which the abnormal 
position sets up, but from interference with the uterine circulation, 
which leads to the effusion of blood, and the death of the ovum. 
An inflamed condition of the cervical and uterine mucous mem- 
branes will act in the same way, should pregnancy have occurred ; 
although such a condition more often prevents conception taking 
place. 

Symptoms. — One of the earliest indications of impending abortion 
is more or less hemorrhage. This may at first be slight, and may 
last for a short time only, recurring after an interval of time ; or it 
may commence with a sudden and profuse discharge. Occasionally 
it is very abundant, and its continuance and amount form one of the 
gravest symptoms of the accident. After the loss of blood has con- 
tinued for a greater or less length of time — it may be even for some 
days — uterine contractions come on, recurring at regular intervals, 
and eventually lead to the expulsion of the ovum. More rarely the 
impending miscarriage commences with pains, which lead to lacera- 
tion of vessels and hemorrhage. 

When Pain and Hemorrhage coexist. — As long as one or other of 
these symptoms exists alone, we may hope to avert the threatened 
miscarriage ; but when both occur together there is little or no 
chance of its being arrested. Certain premonitory symptoms are de- 
scribed by authors as common in abortion, such as feverishness, 
shivering, a sensation of coldness ; all of which are obscure and un- 
reliable, and are certainly much more frequent!}^ absent than present. 

If the pregnancy be early it is probable that the entire ovum will 
be shed with little trouble, and it often passes unperceived in the 
clots which surround it. It is, therefore, of importance that all the 
discharges should be very carefully examined. After the second 
month the rigid and undilated cervix presents a formidable obstacle 
to the escape of the ovum, and it may be a considerable time before 
there is sufficient dilatation to admit of its passage. This is gradually 
effected by the continuance of pains, but not without a severe loss of 
blood. It may be that the amnion is ruptured, and the foetus ex- 
pelled first. After a lapse of time the secundines are also shed, but 
there may be a considerable delay, amounting even to days, before 
this is effected. [If the secundines are not expelled entire, a small 
black remnant or several portions may remain, as we have seen 
lately, for a month, the expulsion being preceded by a discharge of 
blackish blood, and by constitutional symptoms, ending in a mild 
phlegmasia dolens. — Ed.] As long as any portions of the membranes 
are retained in utero, the patient is necessarily subjected to consider- 
able risk, not only from the continuance of hemorrhage, but also from 
septicaemia. Hence it may be laid down as a rule, that we can never 
consider our patient out of danger until we have satisfied ourselves 
that the whole of the uterine contents have been expelled. 

Treatment. — Our first endeavor in any case of impending miscar- 
riage will be, of course, to avert the threatened accident. If hemor- 
rhage has not been excessive, and if, on vaginal examination, which 



236 PREGNANCY. 

should always be practised, we find no dilatation of the os, we may 
entertain a reasonable hope of success. If, on the contrary, we find 
the os beginning to open, if we are able to insert the finger through 
it so as to touch the ovum, especially if pains also exist, we are 
justified in considering abortion to be inevitable, and the indication 
will then be to have the ovum expelled, and the case terminated as 
soon as possible. In the former case the most absolute rest is the 
first thing to insist on. The patient should be placed in bed, not 
overburdened with clothes, in a cool temperature, and she should 
have a light and easily assimilated diet. All movements, even rising- 
out of bed to empty the bladder or bowels, should be absolutely pro- 
hibited. To avert the tendency to the commencement of uterine 
contraction there is no remedy so useful as opium, which must be 
given freely, aud frequently repeated. It may be administered either 
in the form of laudanum, or of Battley's sedative solution, which has 
the advantage of producing less general disturbance. It may be 
advantageously exhibited in doses of from 20 to 30 minims, and re- 
peated after a few hours. A still better preparation is chlorodyne, 
which I have found of extreme value in arresting impending mis- 
carriage, in doses of 15 minims, repeated every third or fourth hour. 
If, from any cause, it is considered unadvisable to give the sedative 
by the mouth, it may be administered in a small starch enema per 
rectum. In all cases it will be necessary to keep the patient more or 
less under the influence of the drug for several days, and until all 
symptoms of miscarriage have passed away. Care should be taken 
that the bowels do not become locked up by the action of the opiates 
— as this might of itself be a cause of irritation — and their constipat- 
ing effects ought to be obviated by small doses of castor oil, or other 
gentle aperient. Various subsidiary methods of treatment have been 
recommended, such as bleeding from the arm, or the local applica- 
tion of leeches in supposed plethoric states of the system ; revulsives, 
such as dry cupping to the loins ; the application of ice, to check 
hemorrhage ; astringents, such as acetate of lead or gallic acid, for 
the same purpose. Most of these, if not hurtful, will be, at least, 
useless. The cases in which venesection would be beneficial are ex- 
tremely rare, and the local applications, especially cold, are much 
more apt to favor, than to prevent, uterine action. 

[ Value of Opium. — As an instance of the value of opium in arrest- 
ing abortion under unfavorable circumstances, we refer to the follow- 
ing case. Mrs. E., a young married lady in affluent circumstances, the 
mother of two children, and of apparently a phthisical tendency, the 
disease being in her family, was taken in labor at 4J months ; the 
intermittent pains being very decided, and the loss of blood con- 
siderable. Under the effects of morphia given at intervals, the pains 
became gradually less frequent and severe, until at the end of ten 
hours they ceased entirely. The uterine development advanced 
without any more interruption, and the patient gave birth to a living- 
female child at the end of nine months. The foetus was a little below 
the average in weight, but lived. — Ed.] 



ABORTION AND PREMATURE LABOR. 237 

Prophylactic Treatment. — In cases of repeated miscarriage in suc- 
cessive pregnancies, a special course of prophylactic treatment is 
indicated, and is often attended with much success. In cases of this 
kind the first indication, and one which ought to be carefully attended 
to, is to seek for and, if possible, to remove or mitigate the cause 
which has given rise to the former abortions. Those causes which 
depend on constitutional states must first be carefully investigated, 
and treated according to the indications present. These may be 
obscure and not easily discovered; but it is certainly unwise to 
assume too readily the existence of what has been called "a habit of 
abortion," which further inquiry may prove to be only an indication 
of constitutional debility, degenerac}' of the placental structures, or 
a latent and unsuspected syphilitic taint. If constitutional debility 
be present to a marked extent, a generous diet and a restorative 
course of treatment (preparations of iron, quinine, and other suitable 
tonics), may effect the desired object. 

Treatment in Cases depending on Local Causes. — Local congestion 
of the uterus, or a general plethoric state of the patient, have often 
been supposed to be efficient causes of recurring abortion. Dr. Henry 
Bennet has especially dwelt on the influence of congestion and abra- 
sions of the cervix in causing premature expulsion of the foetus, 1 and 
recommends the topical application of nitrate of silver, or other 
caustics, to the inflammatory abrasions existing on the neck of the 
womb. Formerly venesection was a favorite remedy; and many 
authors have recommended the local abstraction of blood by leeches 
applied to the groin, or round the anus, or even to the cervix. The 
influence of general plethora is more than doubtful ; and although 
local congestions are, probably, much more effective causes, still it 
would seem more judicious to treat them by rest, and local sedatives, 
rather than by topical applications which, injudiciously applied, might 
produce the very accident they were intended to prevent. 

[Advantages of a Pure Atmosphere. — In one plethoric woman who 
aborted repeatedly in about six weeks after impregnation, and in 
whom depletion failed and opium was inadmissible from cerebral 
disturbance, we at last succeeded in saving the foetus. The lady 
was somewhat rheumatic, and subject to attacks of spasmodic asthma, 
for which she occasionally went to a dry mountainous region, rind- 
ing her pregnant when at this retreat, we kept her there until she 
had long passed the usual time for aborting, when we had her 
brought home. During the period from the third to the eighth 
month she was at times affected with uterine pains, when she was 
kept still in bed until they subsided. In the eighth and ninth months 
there Avas no trouble, and she was delivered at the full period of 
gestation, after having previously miscarried seven times. On one 
occasion, when at home, we had succeeded in checking the action of 
the uterus until the end of the second month, but with the effect of 
producing such extreme prostration, that we were glad to learn that 
the foetus had been expelled. — Ed.] 

1 On Inflammation of the Uterus, p. 432. 



288 PREGNANCY. 

The position of the uterus should be carefully investigated. If it 
be found to be retroflexed, a well-fitting Hodge's pessary should be 
applied, so as to support it until it has completely risen out of the 
pelvis. 

Treatment in Cases depending on Syphilis. — The possibility of 
syphilitic infection should always be inquired into, for this poison 
may act on the product of conception long after all appreciable 
traces of it have disappeared from the infected parent. Should there 
be recurrent abortions in a patient who had formerly suffered from 
syphilis, or whose husband had at any time contracted the disease, 
no time should be lost in using appropriate anti-syphilitic remedies, 
which should invariably be administered both to the husband and 
wife. Diday especially insists that in such cases it is not sufficient 
to submit the father and mother to a mercurial course in the absence 
of pregnancy, but that, as each successive impregnation occurs, the 
mother should again commence anti-syphilitic treatment, even though 
she has no visible traces of the disease. 1 In this way there is reason- 
able ground for hoping that infection of the ovum may be prevented. 
I think, too, that we may be the more encouraged to persevere in 
the treatment of these unfortunate cases, from the fact that the 
syphilitic poison tends to wear itself out. I have seen several cases 
in which this taint, at first, produced early abortion, then each suc- 
cessive pregnancy was of longer duration, until eventually a living 
child was born. 

In fatty degeneration of the chorion villi, and in other morbid states 
of the placenta, which act by preventing the proper nutrition of the 
foetus, and the due aeration of its blood, there is no reliable means 
of treatment except the general improvement of the mother's health. 
Simpson strongly recommended the administration of chlorate of 
potash in cases in which the child habitually dies in the latter 
months of pregnancy, on the supposition that it supplied to the blood 
a large amount of oxygen, and thus made up for any deficiency in 
the supply of that element through the placental tufts. The theory 
is, at best, a doubtful one, although I believe the drug to be unques- 
tionably beneficial in cases of the kind. It probably acts by its tonic 
properties rather than in the manner Simpson supposed. It may be 
given in doses of 15 to 20 grains three times a day, and may be 
advantageously combined with small doses of dilute hydrochloric 
acid. In frequently recurring premature labors with dead children, 
Simpson strongly recommended the induction of premature labor a 
little before the time at which we had reason to believe that the 
foetus had usually perished; or, in other words, before the placental 
disease had advanced sufficiently far to interfere with its nutrition. 
The practice has constantly been adopted with success, and is per- 
fectly legitimate, but the difficulty, of course, is to fix on the right 
time. Careful auscultation of the foetal heart may be of some use in 
guiding us to a decision, as the death of the foetus is generally pre- 

1 Diday, Infantile Syphilis, Syd. Soc. Trans, p. 207. 



ABORTION AND PREMATURE LABOR. 239 

ceded for some days by irregular, tumultuous, and intermittent 
action of the heart. 

There will always remain a certain number of cases in which no 
appreciable cause can be discovered. Under such circumstances 
prolonged rest, at least until the time has passed at which abortion 
formerly took place, will afford the best chance of avoiding a recur- 
rence of the accident. There must always be some difficulty in car- 
rying out this indication, inasmuch as the patient's health is apt to 
suffer in other ways from the confinement, and the want of fresh air 
and exercise which it entails. The strictness with which rest should 
be insisted on must vary in different cases, but it should be specially 
attended to at what would have been the menstrual periods. At 
these times the patient should remain in bed altogether ; at others 
she may lie on a sofa, and, if circumstances permit, spend part of the 
day, at least, in the open air. Sexual intercourse should be pro- 
hibited. Should actual symptoms of abortion come on, the pre- 
ventive treatment, already indicated, may be resorted to. Great 
care, however, should be used in prescribing opiates as preventives, 
and they should be given for a specified time only. I have seen, 
more than once, an incurable habit of opium-eating originate from 
the incautious and too long continued exhibition of the drug in 
such cases. 

When we have satisfied ourselves that abortion is inevitable, we 
must proceed to employ treatment that favors the expulsion of 
the ovum. 

Removal of the Ovum when within reach. — If the os be sufficiently 
dilated, and the pains strong, we may find the ovum separated and 
protruding from the os. We may then be able to detach it by the 
ringer. For this purpose the uterus is depressed from without by 
the left hand, while an endeavor is made to scoop out the ovum with 
the examining finger. If it be out of reach, and yet appears de- 
tached, chloroform should be administered, the whole hand intro- 
duced into the vagina, and the finger into the uterine cavity. The 
complete detachment of the ovum can, in this way, be far more 
readily and safely effected than by using any of the many ovum-for- 
ceps which have been invented for the purpose. 

Plugging of the Vagina. — If the ovum be not sufficiently sepa- 
rated, or the os be undilated, means must be taken to control the 
hemorrhage until the former can be removed or expelled. It is here 
that plugging of the vagina finds its most useful application. This 
may be done in various ways. That most usually employed is filling 
the vagina with a tolerably large sponge, in the interstices of which 
the blood coagulates. A better plan is to soak a number of pledgets 
of cotton- wool in water and tie a string round each. The vagina can 
be completely and effectively packed with these ; and this is best 
done through a speculum. Each pledget should be covered with 
glycerine, which completely prevents the offensive odor which other- 
wise always arises. The pledgets can be removed by traction on the 
strings, but if these are not used much pain is caused in getting them 
out of the vagina. The plug should never be left in for more than 



240 PREGNANCY. 

six or eight hours, after which a fresh one may be inserted if neces- 
sary. Two or three full doses of the liquid extract of ergot, of 3ss 
to 3j each, or a subcutaneous injection of ergotine, may be given 
while the plug is in position. The plug itself is a strong excitant of 
uterine action, and the two combined often effect complete detach- 
ment, so that, on the removal of the tampon, the ovum may be found 
lying loose in the os uteri. If the os be undilated and the ovum en- 
tirely out of reach, the former maybe opened by means of sponge or 
laminaria tents. I think a well prepared sponge tent the most ef- 
fectual, and it can be maintained in sitii by a vaginal plug below it. 
It also- acts as a most efficient plug, effectually controlling all hemor- 
rhage. In a few hours it opens up the os sufficiently to admit the 
finger. 

Retention of the Membranes. — The most troublesome cases are those 
in which the foetus is first expelled, and the placenta and membranes 
remain in utero. As long as this is the case the patient can never be 
considered safe from the occurrence of septicaemia. Dr. Priestley has 
strongly insisted on the importance of removing the secundines as 
soon as possible. There can be no doubt that this should be done 
whenever it is feasible. Cases, however, are frequently met with in 
which any forcible attempt at removal would be likely to prove very 
hurtful, and in which it is better practice to control hemorrhage by 
the plug or sponge tent, and wait until the placenta is detached, 
which it will generally be in a clay or two at most. Under such 
circumstances fetor and decomposition of the secundines may be pre- 
vented by intra-uterine injections of diluted Condy's fluid. Provided 
the os be sufficiently patulous to prevent the collection of the fluid 
in the uterine cavity, and not more than a drachm or two of fluid be 
injected at a time, so as simply to wash away and disinfect decom- 
posing detritus, they can be used with perfect safety. Sometimes cases 
are met with in which the os has entirely closed, and in which we can 
only suspect the retention of the placenta by the history of the case, 
the continuance of hemorrhage, or the presence of a fetid discharge. 
Should we see reason to suspect this the os must be dilated with 
sponge or laminaria tents, and the uterine cavity thoroughly explored 
under chloroform. This condition of things is far from uncommon 
in women who have not had medical assistance from the first, and it 
often gives rise to very troublesome and anxious symptoms. It has 
been said that placentas thus retained have been completely absorbed, 
and cases of the kind have been related by Naegele and Osiander. 
The spontaneous absorption, however, of so highly organized a body 
as the placenta would be a phenomenon of the most remarkable 
character ; and it seems more natural to suppose that, in most cases 
of the kind, the placenta has been cast off without the knowledge of 
the patient. Sometimes the placenta never becomes entirely de- 
tached, and, retaining organic connection with the uterine walls, 
forms what has been called a ' placental polypus.'' This may produce 
secondary hemorrhages, in the same way as an ordinary fibroid poly- 
pus. Barnes recommends the removal of these masses by means of 



ABORTION AND PREMATURE LABOR. 241 

the wire ecraseur. Before their detection the os uteri must be 
opened up. 

Subsequent Management. — The frequency with which abortion leads 
to chronic uterine disease should lead us to attach much more im- 
portance to the subsequent management of the patient than has been 
customarjr. The usual practice is to confine the patient to bed for 
two or three days only, and then to allow her to resume her ordinary 
avocations, on the supposition that a miscarriage requires less sub- 
sequent care than a confinement. The contrary of this is, however, 
most probably the case ; for the uterus has been emptied when it is 
unprepared for involution, and that process is often very imperfectly 
performed. We should, therefore, insist on at least as much atten- 
tion being paid to rest as after labor at term. 



PART III 

LABOR. 



CHAPTEE I. 

THE PHENOMENA OF LABOR. 

Delivery at Term. — In considering delivery at term we have to dis- 
cuss two distinct classes of events. 

One of these is the series of vital actions brought into play in 
order to effect the expulsion of the child ; and the other consists of 
the movements imparted to the child- — the body to be expelled — in 
other words, the mechanism of delivery. 

Causes of Labor. — Before proceeding to the consideration of these 
important topics, a few words may be said as to the determining 
causes of labor. This subject has been from the earliest times a 
qusestio vexata among physiologists ; and many and various are the 
theories which have been broached to explain the curious fact that 
labor spontaneously commences, if not at a fixed epoch, at any rate 
approximately so. It must be admitted that, even yet, there is no 
explanation which can be implicitly accepted. 

Foetal or Maternal Causes. — The explanations which have been 
given may be divided into two classes — those which attribute the 
advent of labor to the foetus, and those which refer it to some change 
connected with the maternal generative organs. 

The former is the opinion which was held by the older accou- 
cheurs, who assigned to the foetus some active influence in effecting 
its own expulsion. It need hardly be said that such fanciful views 
have no kind of physiological basis. Others have supposed that 
there might be some change in the placental circulation, or in the 
vascular system of the foetus, which might solve the mystery. The 
latest hypothesis of this kind, which, however, is not fortified by any 
evidence, is by Barnes, who says : " I rather incline to the opinion 
that when the foetus has attained its full development, when its 
organs are prepared for external life, some change takes place in its 
circulation, which involves a correlative disturbance in the maternal 
circulation, which excites the attempt at labor." 1 

The majority of obstetricians, however, refer the advent of labor 
to purely maternal causes. Among the more favorite theories is one, 
which was originally started in this country by Dr. Power, and 
adopted and illustrated by Depaul, Dubois, and other writers. It is 

• Diseases of Women, p. 434. 



THE PHEXOxVlEXA OF LABOR. 243 

based on the assumption that there is a sphincter action of the fibres 
of the cervix, analogous to that of the sphincters of the bladder and 
rectum, and that when the cervix is taken up into the general 
uterine cavity as pregnancy advances, the ovum presses upon it, irri- 
tates its nerves, and so sets up reflex action, which ends in the estab- 
lishment of uterine contraction. This theory was founded on erro- 
neous conceptions of the changes that occurred in the neck of the 
uterus ; and, as it is certain that obliteration of the cervix does not 
really take place in the manner that Power believed when his theory 
was broached, it is obvious that its supposed result cannot follow. 

Distension of the Uterus. — Extreme distension of the uterus has 
been held to be the determining cause of labor, a view lately revived 
by Dr. King, of Washington, 1 who believes that contractions are in- 
duced because the uterus ceases to augment in capacity, while its 
contents still continue to increase. This hypothesis is sufficiently 
disproved by a number of clinical facts which show that the uterus 
may be subject to excessive and even rapid distension — as in cases 
of hydramnios, multiple pregnancy, and hydatiform degeneration of 
the ovum — without the supervention of uterine contractions. 

Fatty Degeneration of the Decidua. — Another incitor of uterine 
action has been supposed to be the separation of the ovum from its 
connections to the uterine parietes, in consequence of fatty degenera- 
tion of the decidua occurring at the end of pregnane}^. The sup- 
posed result of this change, which undoubtedly occurs, is that the 
ovum becomes so detached from its organic adhesions as to be some- 
what in the position of a foreign body, and thus incites the nerves so 
largely distributed over the interior of the uterus. This theory, 
which has been widely accepted, was originally started by Sir James 
Simpson, who pointed out that some of the most efficient means of 
inducing labor (such, for example, as the insertion of a gum-elastic 
catheter between the ovum and the uterine walls) probably act in 
the same way, viz., by effecting separation of the membranes and 
detachment of the ovum. 

Barnes instances, in opposition to this idea, the fact that ineffect- 
ual attempts at labor come on at the natural term of gestation in 
cases of extra-uterine pregnancy, when the foetus is altogether inde- 
pendent of the uterus, and therefore, he argues, the cause cannot be 
situated in the uterus itself. A fair answer to this argument would 
be that although, in such cases, the womb does not contain the ovum, 
it does contain a decidua, the degeneration and separation of which 
might suffice to induce the abortive and partial attempts at labor 
then witnessed. 

Objections to these Theories. — A serious objection to all these theories, 
which are based on the assumption that some local irritation brings 
on contraction, is the fact, which has not been generally appreciated, 
that uterine contractions are always present during pregnancy as a 
normal occurrence, and that they may be, and often are, readily in- 
tensified at any time, so as to result in premature delivery. 

1 American Journal of Obstetrics, vol. iii. 



244 LABOR. 

It is, indeed, most likely that, at or about the full term, the ner- 
vous supply of the uterus is so highly developed, and in so advanced 
a state of irritability, that it more readily responds to stimuli than 
at other times. If by separation of the decidua, or in some other 
way, stimulation of the excitor nerves is then effected, more frequent 
and forcible contractions than usual may result, and, as they become 
stronger and more regular, terminate in labor. But, allowing this, 
it still remains quite unexplained why this should occur with such 
regularity at a definite time. 

Tyler Smith's Ovarian Theory. — Tyler Smith tried, indeed, to prove 
that labor came on naturally at what would have been a menstrual 
epoch, the congestion attending the menstrual nisus acting as the ex- 
citor of uterine contraction. He, therefore, refers the onset of labor 
to ovarian, rather than to uterine, causes. Although this view is 
upheld with all its author's great talent, there are several objections 
to it difficult to overcome. Thus, it assumes that the periodic changes 
in the ovary continue during pregnancy, of which there is no proof. 
Indeed there is good reason to believe that ovulation is suspended 
during gestation, and with it, of course, the menstrual nisus. Be- 
sides, as has been well objected by Cazeaux, even if this theory were 
admitted, it would still leave the mystery unsolved, for it would not 
explain why the menstrual nisus should act in this way at the tenth 
menstrual epoch, rather than at the ninth or eleventh. 

In spite, then, of the many theories at our disposal, it is to be 
feared that we must admit ourselves to be still in entire ignorance of 
the reason why labor should come on at a fixed epoch. 

Mode in which the Expulsion of the Child is effected. — The expulsion 
of the child is effected by the contractions of the muscular fibres of 
the uterus, aided by those of some of the abdominal muscles. These 
efforts are in the main entirely independent of volition. So far as 
regards the uterine contractions, this is absolutely true, for the 
mother has no power of originating, lessening, or increasing the 
action of the uterus. As regards the abdominal muscles, however, 
the mother is certainly able to bring them into action, and to increase 
their power by voluntary efforts ; but, as labor advances, and as the 
head passes into the vagina and irritates the nerves supplying it, the 
abdominal muscles are often stimulated to contract, through the influ- 
ence of reflex action, independently of volition on the part of the 
mother. 

The Chief Factor in Expulsion. — There can be little doubt that the 
chief agent in the expulsion of the child is the contraction of the 
uterus itself. This opinion is almost unanimously held by accouch- 
eurs, and the influence of the abdominal muscles is believed to be 
purely accessory. Dr. Haughton, however, maintains a view which 
is directly contrary to this. From an examination of the force of 
the uterine contractions, arrived at by measuring the amount of mus- 
cular fibre contained in the walls of the uterus, he arrives at the 
conclusion that the uterine contractions are chiefly influential in rup- 
turing the membranes, and dilating the os uteri, bringing into action, 
if needful, a force equivalent to 54 lbs.; but when this is effected, 



THE PHENOMENA OF LABOR. 245 

and the second stage of labor has commenced, he thinks the remain- 
der of the labor is mainly completed by the contractions of the ab- 
dominal muscles, to which he attributes enormous powers, equivalent, 
if needful, to a pressure of 523.65 lbs. on the area of the pelvic canal. 

These views bear on a topic of primary consequence in the phy- 
siology of labor. They have been fully criticized by Duncan, who 
has devoted much experimental research to the study of the powers 
brought into action in the expulsion of the child. His conclusions 
are that, so far from the enormous force being employed that 
Haughton estimated, in the large majority of cases the effective 
force brought to bear on the child by the combined action of both 
the uterine and abdominal muscles is less than 50 lbs. — that is, less 
than the force which Haughton attributed to the uterus alone. In 
extremely severe labors, when the resistance is excessive, he thinks 
that extra power may be employed; but he estimates the maximum 
as not above 80 lbs., including- in this total the action of both the 
uterine and abdominal muscles. Joulin arrived at the conclusion 
that the uterine contractions were capable of resisting a maximum 
force of about one hundredweight. Both these estimates, it will be 
observed, are much under that of Haughton, which Duncan de- 
scribes as representing "a strain to which the maternal machinery 
could not be subjected without instantaneous and utter destruction." 

There are many facts in the history, of parturition which make it 
certain that the chief factor in the expulsion of the child is the 
uterus. Among these may be mentioned occasional cases in which 
the action of the abdominal muscles is materially lessened, if not 
annulled — as in profound anaesthesia, and in some cases of para- 
plegia — in which, nevertheless, uterine contractions suffice to effect 
delivery. The most familiar example of its influence, however, 
and one that is a matter of everyday observation in practice, is 
when inertia of the uterus exists. In such cases no effort on the 
part of the mother, no amount of voluntary action that she can 
bring to bear on the child, has any appreciable influence on the 
progress of the labor, which remains in abeyance until the de- 
fective uterine action is re-established, or until artificial aid is 
given. 

The contraction of the uterus, then, being the main agent in de- 
livery, it is important for us to appreciate its mode of action, and its 
effect on the ovum. 

Uterine Contractions at the Commencement of Labor. — We have 
seen that intermittent and generally painless uterine contractions 
exist during pregnancy. As the period for delivery approaches, 
these become more frequent and intense, until labor actually com- 
mences, when they begin to be sufficiently developed to effect the 
opening up of the os uteri, with the view to the passage of the 
child. They are now accompanied by pain, which increases as labor 
advances, and is so characteristic that "pains" are universally used 
as a descriptive term for the contractions themselves. It does not 
necessarily follow that uterine contractions are painless until they 
commence to effect dilatation of the os uteri. On the contrary, 



246 LABOR. 

during tne last days or even weeks of pregnancy, women constantly 
have irregular contractions, accompanied by severe suffering, which, 
however, pass off without producing any marked effect on the cer- 
vix. When labor has actually begun, if the hand is placed on the 
uterus when a pain commences, the contraction of its muscular tis- 
sue is very apparent, and the whole organ is observed to become 
tense and hard, the rigidity increasing until the pain has reached its 
acme, the uterine walls then relaxing, and remaining soft until the 
next pain comes on. At the commencement of labor these pains are 
few, separated from each other by a considerable interval, and of 
short duration. In a perfectly typical labor the interval between the 
pains becomes shorter and shorter, while, at the same time, the dura- 
tion of each pain is increased. At first they may occur only once in 
an hour or more, while eventually there may not be more than a few 
minutes' interval between them. 

Mode in ivhich Dilatation of the Cervix is Effected. — If, when the 
pains are fairly established, a vaginal examination be made, the os 
uteri will be found to be thinned and dilated in proportion to the 
progress of the labor. During the contraction the bag of membranes 
will be felt to bulge, to become tense from the downward pressure 
of the liquor amnii within it, and to protrude through the os if it 
be sufficiently open. The membranes, with the contained liquor 
amnii, thus form a fluid wedge, which has a most important influence 
in dilating the os uteri (see Frontispiece). This does not, however, 
form the sole mechanism by which the os uteri is dilated, for it is 
also acted upon by the contractions of the muscular fibres of the 
uterus, which tend to pull it open. It is probable that the muscular 
dilatation of the os is effected chiefly by the longitudinal fibres, which, 
as they shorten, act upon the os uteri, the part where there is least 
resistance. 

Partly then hj muscular contraction, partly by mechanical pres- 
sure, the cervical canal is dilated, and as it opens up it becomes thin- 
ner and thinner, until it is entirely taken up into the uterine cavity. 

Rupture of the Membranes. — There is no longer any obstacle to the 
passage of the presenting part of the child into the cavity of the 
pelvis, and the force of the pains now general^ effects the rupture 
of the membranes, and the escape of the liquor amnii. There is 
often observed, at this time, a temporary relaxation in the frequency 
of the pains, which had been steadily increasing ; but they soon re- 
commence with increased vigor. If the abdomen be now examined 
it will be observed to be much diminished in size, partly in conse- 
quence of the escape of the liquor amnii, partly from the descent of 
the foetus into the pelvic cavity. 

Change in the Character of the Pains. — The character of the pains 
soon changes. They become stronger, longer in duration, separated 
by a shorter interval, and accompanied by a distinct forcing effort, 
being generally described as " the bearing-down" pains. Now is the 
time at which the accessory muscles of parturition come into opera- 
tion. The patient brings them into play in the manner which will 
be subsequently described, and the combined action of the uterine 



THE PHENOMENA OF LABOR. 247 

and abdominal muscles continues until the expulsion of the child is 
effected. 

Mode of Action of the Uterus. — The precise mode of uterine con- 
traction is still somewhat a matter of dispute. It is generally de- 
scribed as commencing in the cervix, passing gradually upwards by 
peristaltic action, the wave then returning downwards towards the 
os uteri. This view was maintained by Wigand, and has been en- 
dorsed by Rigby, Tyler Smith, and many other writers. In support 
of it they instance the fact that, on the accession of a pain, the pre- 
senting part first recedes, the bag of membranes then becomes tense 
and protrudes through the os, and it is not until some time that the 
presenting part of the child itself is pushed down. It is very doubt- 
ful if this view is correct ; and a careful examination of the course 
of the pains would rather lead to the belief that the contractions 
commence at the fundus, where the muscular tissue is most largely 
developed, and gradually proceed downwards to the cervix ; the 
waves of contraction being, however, so rapid that the whole organ 
seems to harden en masse. The apparent recession of the presenting 
part, and the bulging of the bag of membranes, are certainly no 
proof that the contractions begin at the cervix ; for the commencing 
contraction would necessarily push down the fluid in front of the 
head, and cause the membranes to bulge, and the os to become tense, 
before its force was brought to bear on the foetus itself. Indeed did 
the contraction commence at the lower part of the uterus, we should 
expect the opposite of what takes place to occur, and the waters to 
be pushed upwards, and away from the cervix. The fundal origin 
of the contraction is further illustrated by what is observed when 
the hand of the accoucheur is placed in the uterine cavity, as often 
happens in certain cases of hemorrhage or turning; for if a pain 
then comes on, it will be felt to start at the fundus, and gradually 
compress the hand from above downwards. 

Value of the Intermittent Character of the Pains. — The intermittent 
character of the contractions is of great practical importance. Were 
they continuous, not only would the muscular powers of the patient 
be rapidly exhausted, but, by the obliteration of the vessels produced 
by the muscular contraction, the circulation through the placenta 
would be interfered with, and the life of the child imperilled. Hence 
one of the chief dangers of protracted labor, especially after the 
escape of the liquor amnii, is that the uterine fibres may enter into 
a state of tonic rigidity, a condition that cannot be long contiuued 
without serious risks both to the mother and child. 

The fact that the uterine contractions are altogether involuntary 
proves them to be excited — as indeed we would a priori infer from 
our knowledge of the anatomical arrangement of the nerves of the 
uterus — solely by the sympathetic system. Still it is a fact of every- 
day observation that they can be largely influenced by emotions. 
Various stimuli applied to the spinal system of nerves (as for exam- 
ple when the mammae are irritated) have also a marked effect in in- 
ducing uterine contraction. The precise mode in which such influ- 
ence is conveyed to the uterus, in spite of the numerous experiments 



248 LABOR. 

which have been made for the purpose of determining how far labor 
is affected by destruction of the spinal cord, is still a matter of doubt. 
After the foetus has passed through the cervix, the spinal nerves 
distributed to the vagina and perineum are excited by the pressure 
of the presenting part, and, through them, the accessory powers of 
parturition are chiefly brought into play. The contraction of the 
muscles of the vagina itself is supposed to have some influence in 
favoring the expulsion of the foetus after the birth of part of the 
body, and also in promoting the expulsion of the placenta. In the 
lower animals the vagina has a very marked contractile property, 
and is, in some of them, the main agent by which the young are 
expelled. In the human subject this influence is certainly of very 
secondary importance. 

Character and Source of Pa,ins during Labor. — The amount of suf- 
fering experienced during labor varies much in different cases, and 
is in direct proportion to the nervous susceptibility of the patient. 
There are some women who go through labor with little or no pain 
at all. This is proved by the cases (of which there are numerous 
authentic instances recorded) in which labor has commenced during 
sleep, and the child has been actually born without the mother 
awaking. I am acquainted with a lady, who has had a large family, 
who assures me that, though the labor is accompanied by a sense of 
pressure and discomfort, she experiences nothing which can be called 
actual pain. Such a happy state of affairs is, however, extremely 
exceptional, and, in the vast majority of cases, parturition is accom- 
panied by intense suffering during its whole course, in some cases 
amounting to anguish, which has probably no parallel under any 
other condition. 

The precise cause of the pain has been much discussed, and is, no 
doubt, complex. 

In the First Stage. — In the early stage of labor, and before the dila- 
tation of the os, it is chiefly seated in the back, from whence it shoots 
round the loins and down the thighs. It is then probably produced, 
partly by pressure on the nerve filaments caused by contraction of the 
muscular fibres to which they are distributed, and partly by stretch- 
ing and dilatation of the muscular tissue of the cervix. M. Beau 
believes that in this stage the pain is not produced, strictly speaking, 
in the uterus itself, but is rather a neuralgia of the lumbo- abdominal 
nerves. The pains at this time are generally described as "acute" 
and "grinding," terms which sufficiently well express their nature. 
In highly nervous women these pains are often much less well borne 
than those of a later stage, and the suffering they undergo is indicated 
by their extreme restlessness and loud cries as each contraction 
supervenes. As the os dilates, and the labor advances into the ex- 
pulsive stage, other sources of suffering are added. 

In the Second Stage. — The presenting part now passes into the va- 
gina and presses on the vaginal nerves, as well as on the large ner- 
vous plexuses lying in the pelvis. As it descends lower it stretches 
the perineum and vulva, and presses on the bladder and rectum. 
Hence cramps are produced in the muscles supplied by the nerve 



THE PHENOMENA OF LABOR. 249 

plexuses, as well as an intolerable sense of tearing and stretching in 
the vulva and perineum, and often a distressing feeling of tenesmus 
in the bowels. By this time the accessory muscles of parturition are 
brought into action, and they, as well as the uterine muscles, are 
thrown into frequent and violent contractions, which, independently 
of the other causes mentioned, are sufficient of themselves to produce 
great pain, likened to that of colic, produced by involuntary and 
repeated contraction of the muscles of the intestines. 

Taking all these causes into consideration, there is no lack of suf- 
ficient explanation of the intolerable suffering which is so constant 
an accompaniment of child-birth. 

Effect of the Pains on the Mother and Foetus. — The effect of the pains 
on the mother's circulation is well marked. The rapidity of the pulse 
increases distinctly with each contraction, and, as the pain passes 
off, it again declines to its former state. A similar observation has 
been made with regard to the sounds of the foetal heart, especially 
after the expulsion of the liquor amnii. Hicks has pointed out that 
during a pain the muscular vibrations give rise to a sound which 
often resembles that of the foetal heart, and which completely disap- 
pears when the muscular tissue relaxes. The effect of the pain in 
intensifying the uterine souffle has been already mentioned. The 
strong muscular efforts would naturally lead us to expect a marked 
elevation of temperature during labor.. Further observations on this 
point are required ; but Squire asserts that there is generally only a 
very slight increase in temperature during delivery, rapidly passing 
off as soon as labor is over. 

Division of Labor into Stages. — Such being the physiological facts 
in connection with the labor pains, we may now describe the ordinary 
progress of a natural labor — that is, one terminated by the natural: 
powers, and with a head presenting. 

For facility of description obstetricians have long been in the habit 
of dividing the course of labor into stages, which correspond pretty 
accurately with the natural sequence of events. For this purpose' 
we generally talk of three stages : viz., 1, from the commencement 
of regular pains until the complete dilatation of the cervix ; 2, from, 
the complete dilatation of the cervix until the expulsion of the child ; 
8, the concluding stage, comprising the permanent contraction of the 
uterus, and the separation and expulsion of the placenta. To these 
we may conveniently add a preparatory stage, antecedent to the 
regular commencement of the labor. 

Preparatory Stage. — For a short time before delivery, varying from 
a few days to a week or two, certain premonitory symptoms gene- 
rally exist, which indicate the approaching advent of labor. Some- 
times they are well marked, and cannot be mistaken ; at others they 
are so slight as to escape observation. Amongst the most common 
is a sinking of the uterus into the pelvic cavity, resulting from the 
relaxation of the soft parts preceding delivery. The result is, that 
the upper edge of the uterine tumor is less high than before, and, in 
consequence, the pressure on the respiratory organs is diminished,, 
and the woman often feels lighter, and altogether less unwieldy,, 
17 



250 LABOR. 

than in the previous weeks. If a vaginal examination be made at 
this time, the lower segment of the uterus will be found to have sunk 
lower into the pelvic cavity ; and the consequence of this is that, 
while the respiration is less embarrassed, and the patient feels less 
bulky, other accompaniments of pregnancy, such as hemorrhoids, 
irritability of the bladder and bowels, and oedema of the limbs, be- 
come aggravated. The increased pressure on the bowels often induces 
a sort of temporary diarrhoea, which is so far advantageous that it 
empties the bowels of faeces which may have collected within them. 
As has already been pointed out, the contractions which have been 
going on at intervals during the latter months of pregnancy now get 
more and more marked, and they have the effect of producing a real 
shortening of the cervix, which is of great value preparatory to its 
dilatation. More marked mucous discharge from the cavity of the 
cervix also generally occurs a short time before labor, and it is not 
infrequently tinged with blood from the laceration of minute capillary 
vessels. This discharge, popularly known as the " shows" is a pretty 
sure sign that labor is not far off. It may, however, be entirely 
absent, even until the birth of the child. When copious it serves to 
lubricate the passages, and is generally coincident with rapid dilata- 
tion of the parts, and a speedy labor. 

False Pains. — During this time (premonitory stage) painful uterine 
contractions are often present, which, however, have no effect in 
dilating the cervix. In some cases they are frequent and severe, 
and are very apt to be mistaken for the commencement of real labor. 
Such "false pains" as they are termed, are often excited and kept 
up by local irritations, such as a loaded or disordered state of the in- 
testinal canal ; and they frequently give rise to considerable distress, 
and much inconvenience both to the patient and practitioner. They 
are, it should be remembered, only the normal contractions of the 
uterus, intensified and accompanied with pain. 

First Stage, or Dilatation. — As labor actually commences, the 
uterine contractions become stronger, and the fact that they are 
" true" pains can be ascertained by their effect on the cervix. If a 
vaginal examination be made during one of these, the membranes 
will be felt to become tense and bulging during the pain, and the os 
uteri will be found partially dilated, and thinned at its edges. As 
labor advances this effect on the os becomes more and more marked. 
At first the dilatation is very slight, perhaps not more than enough 
to admit the tip of the examining finger, and both the upper and 
lower orifices of the cervix can be made out. As the pains get 
stronger and more frequent, dilatation proceeds in the way already 
described, and the cervix gets more thin and tense, until we can feel- 
a thin circular ring (which is lax between the pains, but becomes 
rigid and tense during the contraction when the bag of water bulges 
through it), without any distinction between the upper and lower 
orifices. During this time the patient, although she may be suffer- 
ing acutely, is generally able to sit up and walk about. The amount 
of pain experienced varies much according to the character of the 
patient. In emotional women of highly-developed nervous suscepti- 



THE PHENOMENA OF LABOR. 251 

bilities it is generally very great. They are restless, irritable, and 
desponding, and when the pain comes on cry ont loudly. The 
character of the cry is peculiar and well marked during the first stage, 
and has constantly been described by obstetric writers as charac- 
teristic. It is acute and high, and is certainly very different from 
the deep groans of the second stage, when the breath is involuntarily 
retained to assist the parturient effort. When dilatation is nearly 
completed various reflex nervous phenomena often show themselves. 
One of these is nausea and vomiting, another is uncontrollable 
shivering, which is not accompanied by a sense of coldness, the 
patient being often hot and perspiring. Both these symptoms indi- 
cate that the propulsive stage will shortly commence ; and they may 
be regarded as favorable rather than otherwise, although they are 
apt to alarm the patient and her friends. By this time the os is fully 
dilated, the membranes generally rupture spontaneously, and a con- 
siderable portion of the liquor amnii flows away. The head, if pre- 
senting, often acts as a sort of ball- valve, and, falling down on the 
aperture of the cervix, prevents the complete evacuation of the 
liquor amnii, which escapes by degrees during the rest of the labor, 
or may be retained in considerable quantity until the birth of the 
child. 

It not infrequently happens, if the membranes are somewhat 
tougher than usual, and the pains frequent and strong, that the 
foetus is pushed through the pelvis, and even expelled, surrounded 
by the membranes. When this occurs the child is said to be born 
with a "caul" and this event would doubtless happen more fre- 
quently than it does, were it not the custom of the accoucheur to 
rupture the membranes artificially as soon as the os is completely 
opened up, after which time their integrity is no longer of any value. 

Second Stage, or Propulsion. — The os is now entirely retracted over 
the presenting part, and is no longer to be felt, the vagina and the 
uterine cavity forming a single canal. Now the mucous discharge is 
generally abundant, so that the examining finger brings away long 
strings of glairy transparent mucus, tinged with blood. The pains, 
after a short interval of rest, become entirely altered in character. 
The uterus contracts tightly round the foetus, the presenting part de- 
scends into the pelvis, and the true propulsive pains commence. The 
accessory muscles of parturition now come into play. With each 
pain the patient takes a deep inspiration, and thus fills the chest, so 
as to give a point oVappui to the abdominal muscles. For the same 
reason she involuntarily seizes hold of some point of support, as the 
hand of a bystander or a towel tied to the bed, and, at the same time 
pushes with her feet against the end of the bed, and so is able to 
bear down to advantage. The cries are no longer sharp and loud, 
but consist of a series of deep suppressed groans, which correspond 
to a succession of short expirations made during the straining effort. 
In this way the abdominal muscles contract forcibly on the uterus, 
which they further stimulate to action by pressing upon it. It is to 
be observed that these straining efforts are, to a considerable extent, 
under the control of the patient. By encouraging her to hold her 



252 LABOR. 

breath and bear down they can be intensified ; while if we wish to 
lessen them we can advise her to call out, and when she does so the 
abdominal muscles have no longer a fixed point of action. Although 
the patient may thus lessen the effect of these accessory muscles, it 
is entirely out of her power to stop their action altogether. As labor 
advances the head descends lower and lower, receding somewhat in 
the intervals between the pains, until eventually it comes down on 
the perineum, which it soon distends. 

Distension of the Perineum and Birth of the Child. — The pains now 
get stronger and more frequent, often with scarcely a perceptible in- 
terval between them, until the perineum gets stretched by the ad- 
vancing head. In the interval between the pains elasticity of the 
perineal structures pushes the head upwards, so as to diminish the 
tension to which the perineum is subjected, the next pain again put- 
ting it on the stretch, and protruding the head a little further than 
before. By this alternate advance and recession, the gradual yield- 
ing of the structures is favored, and risk of laceration greatly dimin- 
ished. During this time the pressure of the head mechanically 
empties the bowel of its contents. During the last pains, when the 
perineum is stretched to the utmost, the anal aperture is dilated, 
sometimes to the size of a five-shilling piece ; and in this way the 
perineum is relaxed, just as the distension, and consequent risk of 
laceration, are at their maximum. The apex of the head now pro- 
trudes more and more through the vulva, surrounded by the orifice 
of the vagina, and eventually it glides over the perineum and is 
expelled. The intensity of the suffering at this moment generally 
causes the patient to call out loudly. The force of the abdominal 
muscles is thus lessened at the last moment, and this, in combination 
with the relaxation of the sphincter ani, forms an admirable con- 
trivance for lessening the risk of perineal injury. The rest of the 
body is generally expelled immediately by a single pain, and with it 
are discharged the remains of the liquor amnii, and some blood- clots 
from separation of the placenta ; and so the second stage of labor 
terminates. 

The Third Stage. Its Importance. — The third stage commences 
after the expulsion of the child. It is of paramount importance to 
the safety of the mother that it should be conducted in a natural 
and efficient manner ; for it is now that the uterine sinuses are closed, 
and the frail barrier by which nature effects this may be very readily 
interfered with, and serious and even fatal loss of blood ensue. Un- 
fortunately, it is too often the case that the practitioner's entire at- 
tention is fixed on the expulsion of the child, so that the natural 
history of the rest of delivery is very generally imperfectly studied 
and understood. 

Contraction of the Uterus and Detachment of the Placenta. — As soon 
as the child is expelled, the uterine fibres contract in all directions, 
and the hand, following the uterus down, will find that it forms a 
firm rounded mass lying in the lower part of the abdominal cavity. 
By retraction of its internal surface, the placental attachments are 



THE PHENOMENA OF LABOR. 



253 



Fig. 91. 



generally separated, and the after-birth remains in the cavity of the 
uterus as a foreign body. 

Mode in which Hemorrhage is Prevented. — The escape of blood from 
the open mouths of the uterine sinuses is now prevented in two ways : 
viz., (1) by the contraction of the uterine walls, and the more firm, 
persistent, and tonic this is, the more certain is the immunity from 
hemorrhage ; (2) by the formation of coagula in the mouths of the 
vessels. Auy undue haste in promoting the expulsion of the pla- 
centa tends to prevent the latter of these two hemostatic safeguards, 
and is apt to be followed by loss of blood. After a certain time, 
averaging from a quarter to half an hour, the uterus will be felt to 
harden, and, if the case be solely left to nature, what has been aptly 
called a miniature labor occurs. Pains come on, and the placenta is 
spontaneously expelled from the uterus, either into the canal of the 
vagina, or even externally. In most obstetric works it is stated that 
the after-birth may be separated either from its centre or edge, and 
that it is very generally expelled through the os 
in an inverted form, with its foetal surface down- 
wards, and folded transversely on itself. That 
this is the mode in which the placenta is often 
expelled, when traction on the cord is practised, 
is a matter of certainty. It then passes through 
the os very much in the shape of an inverted 
umbrella. It is certain, however, that this is 
not the natural ' mechanism of its -delivery. 
AY hat this is has been well illustrated by Dun- 
can, 1 who has very clearly shown that, when this 
stage of labor is left entirely to nature, the sepa- 
rated placenta is expelled edgeways, its uterine 
and detached surface gliding along the inner sur- 
face of the uterus, the foldings of its structure 
being parallel to the long diameter of the uter- 
ine cavity (Fig. 91). In this way it is expelled 
into the vagina, and during the process little or 
no hemorrhage occurs. When the placenta is 
drawn out in the way too generally practised, it 
obstructs the aperture of the os, and, acting like 
the piston of a pump, tends to promote hemorrhage. The corol- 
laries as to treatment drawn from these facts will be subsequently 
considered. I am anxious, however, here to direct attention to na- 
ture's mechanism, because I believe there is no part of labor about 
the management of which erroneous views are more prevalent than 
that of this stage, and none in which they are more apt to lead to 
serious consequences ; and unless the mode in which nature effects 
the expulsion of the placenta, and prevents hemorrhage, is thoroughly 
understood, we shall certainly fail in assisting her in a proper man- 
ner. In the large proportion of cases, when left entirely to them- 
selves, the placenta would be retained, if not in the uterus, at any rate 




Mode in which the Placenta 

is Xaturally Expelled. 

(After Duncan.) 



Edin. Med. Jour., April, 1871. 



25-1 LABOR. 

in the vagina, for a considerable time — possibly for several hours — 
and such delay would very unnecessarily tire the patience of the 
practitioner, and be prejudicial to the patient. It is, therefore, our 
duty in the majority of cases, to promote the expulsion of the after- 
birth ; and when this is properly and scientifically done, we increase, 
rather than diminish the patient's safety and comfort. But, in order 
to do this, we must assist nature, and not act in opposition to her 
method, as is so often the case. 

After-pains. — When once the placenta is expelled, the uterus con- 
tracts still more firmly, and, in a typical case, is felt just within the 
pelvic brim, hard and firm, and about the size of a cricket ball. 
Generally for several hours, or even for one or two days, it occasion- 
ally relaxes and contracts, and these contractions give rise to the 
" after-pains 11 from which women often suffer much. The object of 
these pains is, no doubt, to expel any coagula that may remain in 
the uterus, and therefore, however unpleasant they may be to the 
patient, they must be considered, unless very excessive, to be salutary 
rather than otherwise. 

Duration of Labor. — The length of labor varies extremely in dif- 
ferent cases, and it is quite impossible to lay down any definite rules 
with regard to it. Subject to exceptions, labor is longer in primi- 
parse than in multipara, on account of the greater resistance of the 
soft parts in the former, especially of the structures about the vagina 
and vulva. It is also generally stated that the difficulty of labor 
increases with the age of the patient, and that in elderly primiparse 
it is likely to be unusually tedious from rigidity of the soft parts. 
It is very doubtful if this opinion has any real basis, and in such 
cases the practitioner often finds himself agreeably disappointed on 
the result. Mr. Eoper, 1 indeed, argues that the wasting of the tissues 
which occurs after forty years of age diminishes their resistance, and 
that first labors, after that age, are easier, as a rule, than in early 
life. The habits and mode of life of patients have, no doubt, a con- 
siderable influence on the duration of labor, but we are not in posses- 
sion of any very reliable facts with regard to this subject. It is 
reasonable to suppose that the tissues of large, muscular, strongly 
developed women will offer more resistance than those of slighter 
build. On the other hand, women of the latter class, especially in 
the upper ranks of life, more often develop nervous susceptibilities, 
which may be expected to influence the length of their labors. The 
average duration of labor, calculated from a large number of cases, 
is from eight to ten hours ; even in primiparae, however, it is con- 
stantly terminated in one or two hours from its commencement, and 
may be extended to twenty-four hours without any symptoms of 
urgency arising. In multipara it is frequently over in even a shorter 
time. Indications calling for interference may arise at any time 
during the progress of labor, independently of its length. The pro- 
portion between the length of the first and second stages also varies 
considerably. The first stage is generally the longest ; and it is 

1 Obst. Trans., v. 7. 



DELIVERY IN HEAD PRESENTATIONS. 255 

stated by Cazeaux to be normally about twice the length of the 
second. This is probably under the mark, and I believe Joulin to 
be nearer the truth in stating that the first stage should be to the 
second as four or five to one, rather than as two to one. Often when 
the first stage has been very prolonged, the second is terminated 
rapidly. 

Necessity of Caution in expressing an Opinion as to the possible 
Duration of Labor. — The practitioner is constantly asked as to the 
probable length of labor, and the uncertainty of this should always 
lead him to give a most guarded opinion. Even when labor is pro- 
gressing apparently in the most satisfactory manner, the pains fre- 
quently die away, and delivery may be delayed for many hours. In 
the first stage a cervix that is apparently rigid and unyielding may 
rapidly and unexpectedly dilate, and delivery soon follow. In either 
case, if the practitioner has committed himself to a positive opinion 
he is apt to incur blame, and it is far better always to be extremely 
cautious in our predictions on this point. 

Period of the Day at which Labor Occurs. — A somewhat larger pro- 
portion of deliveries occur in the early hours of the morning than at 
other times. Thus Westbound that out of 2019 deliveries, 780 took 
place from 11 P.M. to 7 A.M., 662 from 7 A.M. to 3 P.M., and 577 
from 3 P.M. toll P.M. 



CHAPTEK II. 

MECHANISM OF DELIVERY IN HEAD PRESENTATIONS. 

Importance of the Subject. — It is quite impossible to over-estimate 
the importance of thoroughly understanding the mechanism of the 
passage of the foetus through the pelvis. This dominates the whole 
scientific practice of midwifery, and the practitioner cannot acquire 
more than a merely empirical knowledge, such as may be possessed 
by any uneducated midwife, or to conduct the more difficult cases 
requiring operative interference, with safety to the patient or satis- 
faction to himself, unless he thoroughly masters the subject. 

In treating of the physiological phenomena of labor, it was 
assumed that we had to do with an ordinary case of head presenta- 
tion, the description being applicable, with slight variations, to pre- 
sentations of other parts of the foetus. So in discussing the mechanical 
phenomena of delivery, I shall describe more in detail the mechanism 
of head presentation, reserving any account of the mechanism of 
other presentations until they are separately studied. Head presen- 

1 Amer. Med. Journ., 1854. 



256 LABOE. 

tation is so much more frequent than that of any other part — 
amounting to 95 per cent, of all cases — that this mode of studying 
the subject is fully justified; and, when once the student has mastered 
the phenomena of delivery in head presentations, he will have little 
difficulty in understanding the mechanism of labor when other parts 
of the foetus present, based, as it always is, on the same general plan. 

Position of the Head by its Sutures and Fontanelles. — In entering on 
this study we come to appreciate the importance of the sutures and 
fontanelles in enabling us to detect the position of the foetal head, 
and to watch its progress through its canal; and unless the "tactus 
eruditus" by which these can be distinguished from each other has 
been acquired, the practitioner will be unable to satisfy himself of 
the exact progress of the labor. Nor is this always easy. Indeed, 
it requires considerable experience and practice before it is possible 
to make out the position of the head with absolute certainty; but 
this knowledge should always be aimed at, and the student will never 
regret the time and trouble he spends in acquiring it. 

Position of the Head at the commencement of Labor. — At the com- 
mencement of labor the long diameter of the head lies in almost any 
diameter of the pelvic brim, except in the antero-posterior, where 
there is not space for it. In the large majority of cases, however, it 
enters the pelvis in one or other of the oblique diameters, or in one 
between the oblique and transverse ; but until it has fairly passed 
through the brim, it more frequently lies directly in the transverse 
diameter than has been generally supposed. Hence obstetricians are 
in the habit of describing the head as lying in four positions, accord- 
ing to the parts of the pelvis to which the occiput points ; the first 
and third positions being those in which the long diameter of the 
head occupies the right oblique diameter of the pelvis, the second 
and fourth those in which it lies in the left oblique. Many sub- 
divisions of these positions have been made, which only complicate 
the subject, and render it more difficult to understand. 

The positions, then, of the foetal head after it has entered the brim, 
which it is of importance to be able to distinguish in practice are : — 

First (or left occipito -cotyloid). — The occiput points to the left fora- 
men ovale, the sinciput to the right sacro-iliac synchondrosis, and 
the long diameter of the head lies in the right oblique diameter of 
the pelvis. 

Second (or right occipito- cotyloid). — The occiput points to the right 
foramen ovale, the forehead to the left sacro-iliac synchondrosis, and 
the long diameter of the head lies in the left oblique diameter of the 
pelvis. 

Third (or right occipito -sacro-iliac). — The occiput points to the right 
sacro-iliac synchondrosis, the forehead to the left foramen ovale, and 
the long diameter of the head lies in the right oblique diameter of 
the pelvis. This position is the reverse of the first. 

Fourth (or left occipito-sacro-iliac). — The occiput points to the left 
sacro-iliac synchondrosis, the forehead to the right foramen ovale, 
and the long diameter of the head lies in the left oblique diameter of 
the pelvis. This position is the reverse of the second. 



DELIVERY IN HEAD PRESENTATIONS. 257 

Frequency of these Positions. — The relative frequency of these 
positions has long been, and still is, a matter of discussion among 
obstetricians. According to Naegele, to whose classical essay we 
owe the greater part of our knowledge of the subject, the head lies 
in the right oblique diameter in 99 per cent, of all cases. More re- 
cent researches have thrown some doubt on the accuracy of these 
figures, and many modern obstetricians believe that the second posi- 
tion, which Xaegele believed only to be observed as a transitional 
stage in the natural progress of the third position, is much more 
common than he supposed. This question will be more fully dis- 
cussed when we treat of the mechanism of occipito-posterior delivery, 
and, in the meantime, it may serve to show the discrepancy which 
exists in the opinions of modern writers, if we append the following 
table of the relative frequency of the various positions, 1 copied from 
Leishman's Work: — 



Naegele 

Xaegele, Jun. . 

Simpson and Barry 

Dubois 

Murphy 

Swayne 



First 
Position. 


Second 
Position. 


Third 
Position. 


Fourth 

Position. 


70. 

64.64 

76.45 

70.83 

63.23 

86.36 




29. 
32.88 
22.68 
25.66 
16.18 
1.04 






.58 

.62 
4.42 
2.8 

[ 


.29 

■ 2.87 

16.18 

9.79 



Not 
Classified 



1. 

2.4; 



Here it will be seen that all obstetricians are agreed as to the im- 
mensely greater frequency of the first position — the only point at 
issue being the relative frequency of the second and third. 

Explanation. — Various explanations have been given of the 
greater frequency with which the head lies in the right oblique 
diameter. By some it is referred to the natural tendency of the back 
of the foetus, as shown by the experimental researches of Honing 
and other writers, to be directed, in consequence of gravitation, for- 
wards and to the left side of the mother in the erect attitude, and 
backwards and to her right side in the recumbent. The explanation 
given by Simpson was that the head lay in the right oblique diame- 
ter in consequence of the measurement of the left oblique being more 
or less lessened by the presence of the rectum. When the rectum is 
collapsed, indeed, the narrowing of the diameter is slight ; but it is 
so often distended by faecal matter — sometimes, when constipation 
exists, to a very great extent — that it may really have a very 
important influence in determining the position of the foetal head. 

In describing the mechanism of delivery, it will be well for us to 
concentrate our attention on the first, or most common position, 
dwelling, subsequently more briefly on the differences between it and 
the less common ones. 

Description of the First Position. — In this position, when the head 



Leishman's System of Midwifery, p. 341. 



258 



LABOR. 



commences to descend, the occiput lies in the brim pointing to the 
left ileo-pectineal eminence, the forehead is directed to the right 
sacro-iliac synchondrosis, and the sagittal suture runs obliquely 
across the pelvis in the right oblique diameter. The back of the 
child is turned towards the left side of the mother's abdomen, the 
right shoulder to her right side, the left to her left side (Fig. 92). If 



Fig. 92. 




Attitude of Child in First Position. (After Hodge.) 

a vaginal examination be now made (the patient lying in the ordinary 
obstetric position), and the os be sufficiently open, the finger will 
impinge upon the protuberances of the right parietal bone, which is 
described as the "presenting part," a term which has received various 
definitions, the best of which is probably that adopted by Tyler 
Smith, viz., "that portion of the foetal head felt most prominently 
within the circle of the os uteri, the vagina, and the os tincse, in the 
successive stages of labor." If the tip of the examining finger be 
passed slightly upwards, it will feel the sagittal suture running 
obliquely across the pelvis and, if this be traced downwards and to 
the left, it will come upon the triangular posterior fontanelle, with 
the lamboidal sutures diverging from it. If the finger could be 
passed sufficiently high in the opposite direction, upwards and to the 
right, it would come upon the large anterior fontanelle; but, at this 
time, that is too high up to be within reach. The chin is slightly 
flexed upon the sternum, this flexion, as we shall presently see, 
being greatly increased as the head begins to descend. 

The head, at the commencement of labor, generally lies within the 
pelvic brim, especially in primiparas. In multiparas, owing to the 
relaxation of the abdominal parietes, the uterus is apt to fall some- 



DELIVERY IN HEAD PRESENTATIONS 



259 



what forwards, and the head consequently is more entirely above the 
brim, but is pushed within it as soon as labor actually commences. 

NaeyeWs Views. — Naegele — and his description has been adopted 
by most subsequent writers — describes the head, at this period, as 
lying obliquely in relation to the brim, the right parietal bone, on 
which the examining finger impinges, being supposed by him to be 
much lower than the left. The accuracy of this view has, of late 
years, been contested, and it is now pretty generally admitted that 
this obliquity does not exist, and that the head enters the brim of 
the pelvis with both parietal bones on the same level, and with its 
biparietal diameter parallel to the plane of the inlet (Fig. 93). Nae- 

Fig. 93. 




First Position : Movement of Flexion. 



gele's view was adopted, partly because the finger always felt the 
right parietal protuberance lowest, and partly because it was at that 
point that the u cajjut succedaneum" or swelling observed on the head 
after delivery, was always formed. Both arguments are, however, 
fallacious ; for the right parietal bone is the part which would natu- 
rally be felt lowest, on account of the oblique position of the pelvis 
to the trunk; while, with regard to the caput succedaneum, it has 
been conclusively proved by Duncan, that it does not form on the 
point most exposed to pressure, as ISTaegele assumed, but on the part 
of the head where there is least pressure, that is the part lying over 
the axis of the vaginal canal. 

Division of Mechanical Movements into Stages. — In tracing the pro- 
gress of the head from the position just described, obstetricians have 
been in the habit of dividing the movements it undergoes into vari- 
ous stages, which are convenient for the purpose of facilitating de- 
scription. It must be borne in mind that these are not evident and 
distinct stages, which can always be made out in practice, but that 
they run insensibly into one another, and often occur simultaneously, 



260 LABOR. 

or nearly so, in rapid labor. They may oe described as: 1. Flexion. 
2. First movement of descent. 3. Levelling or adjusting movement. 
4. Rotation. 5. Second movement of descent and extension. 6. Ex- 
ternal rotation. 

1. Flexion, the first movement of the head, consists of a rotation 
on its bi-parietal diameter, by which the chin of the child becomes 
bent on the sternum, and the occiput descends lower than the front 
part of the head. By this there is a clear gain of at least a half inch, 
for the occipito-bregmatic diameter (3J inches) becomes subsituted 
for the occipito-frontal (4 inches) (Fig. 93). 

The movement is most marked when the pelvis is narrow, and, in 
some cases of pelvic deformity, it takes place to an extreme degree ; 
while, in unusually large and roomy pelves, it occurs to a very slight 
extent, or not at all. The reason of this flexion is twofold. Solayres 
and the majority of obstetricians explain it by saying that the ex- 
pulsive force is communicated to the head through the vertebral 
column, and, inasmuch as the head is articulated much nearer the 
occiput than the sinciput, the resistance being equal, the former must 
be pushed down. This is doubtless the correct explanation of the 
flexion after the membranes are ruptured ; but, before that happens, 
the ovum is practically a bag of water, which is equally compressed 
at all points by the uterine contractions, and is pushed downwards 
through the os en masse, the expulsive force not being transmitted 
through the vertebral column at all. Under such circumstances 
flexion is probably effected in the following way: the head being ar- 
ticulated nearer the occiput than the forehead, and being equally 
pressed upon from below by the resisting structures, the pressure is 
more effectual on the forehead — consequently that is forced up- 
wards, and the occiput descends. This explanation would also hold 
good after the rupture of the membranes, and probably both causes 
assist in effecting the movement. 

2 and 3. Descent and Levelling Movement. — The movements of 
descent and levelling may be described together. As soon as the head 



Fig. 94. 








First Position : Occiput in the cavity of Pelvis. (After Hodge.) 

is liberated from the os uteri, it descends pretty rapidly through the 
pelvis, until the occiput reaches a point nearly opposite the lower 
part of the foramen ovale (Fig. 94), and the sinciput is opposite the 
second bone of the sacrum. A levelling movement now occurs, the 



DELIVERY IN HEAD PRESENTATIONS. 261 

anterior fontanelle comes to be more easily within reach, more on a 
level with the posterior, and the chin is no longer so much flexed on 
the sternum. This change is due to the fact that the anterior end 
of the ovoid experiences greater resistance than the posterior, and 
as soon as this resistance counterbalances and exceeds that applied 
to the latter, the sinciput must descend. The right side of the head 
also descends more than the left from a similar cause, so that the 
head becomes, as it were, slightly flexed on the right shoulder. This 
obliquity of the head on its transverse diameter in the lower part of 
the pelvis has been denied by Kiineke, 1 who maintains that the head 
passes through the entire pelvis in the same position as it enters the 
brim, that is, with both parietal bones on a level, so that the point 
of intersection of the transverse and antero-posterior diameters of 
the pelvis would correspond with the sagittal suture. There is, 
however, good reason to believe that, in the lower half of the pelvic 
cavity, the head is not truly synclitic, as Kiineke describes, but 
that the right parietal bone is on a somewhat lower level than the 
left. 

4. Rotation. — The movement of rotation is very important. By it 
the long diameter of the head is changed from the oblique diameter 
of the pelvic cavity to the antero-posterior diameter of the outlet 
(Fig. 95), or to a diameter nearly corresponding to it, so that the 

Fig. 95. 




First Position : Occiput at outlet of Pelvis. (After Hodge. 



long diameter of the head is brought into relation with the longest 
diameter of the pelvic outlet. This alteration almost always takes 
place, and may be readily observed by the accoucheur who carefully 
watches the progress of labor. Various explanations have been 
given of its causes. The one most generally adopted is, that it is 
due to the projection inwards of the ischial spines, which narrow the 
transverse diameter of the pelvic outlet. As the pains force the 
occiput downwards, its rotation backwards is prevented by the pro- 
jection of the left ischial spine, while its rotation forwards is favored 
by the smooth bevelled surface of the ascending ramus of the 
ischium. Similarly the ischial spine on the opposite side prevents 
the rotation forwards of the forehead, which is guided backwards to 
the cavity of the sacrum by the smooth surface of the sacro-ischi- 

1 Die Vier Factoren der Geburt, Berlin, 1869. 



262 LABOR. 

atic ligaments. These arrangements, therefore, give a screwlike 
form to the interior of the pelvis ; and as the pains force the head 
downwards, they are effectual in imparting to it the rotatory move- 
ment which is of such importance in adapting it to the longest 
measurement of the outlet. 

By most of the German obstetricians the influence of the ischial 
spines, and of the smooth pelvic planes in producing rotation is not 
admitted. They rather refer the change of direction to the in- 
creased resistance the head meets from the posterior wall of the 
pelvis, and from the perineal structures. Whichever part of the 
head first meets this resistance, which is much greater than that of 
the anterior part of the pelvis, must necessarily be pressed forwards ; 
and as, in the large majority of cases, the posterior fontanelle de- 
scends first, it is thus pressed forwards until rotation is effected. 
This view has the advantage of accounting equally well for the rota- 
tion in occipito-posterior as in occipito-anterior positions, the former 
of which, on the more ordinarily received theory, are not quite satis- 
factorily explicable. It does not follow that the smooth surfaces of 
the pelvic planes are without influence in favoring the rotation. On 
the contrary, they probably greatly facilitate it ; but it is more sim- 
ply and effectually explained by the latter theory than by that 
which attributes so important an action to the ischial spines. 

In some rare cases the head escapes rotation and reaches the pe- 
rineum still lying in the oblique diameter. Even here, however, 
rotation is generally effected, often suddenly, just as the head is about 
to pass the vulva, and it is very rarely expelled in the oblique posi- 
tion. The movement at this stage may be explained by the peri- 
neum, which is attached at its sides, and grooved in its centre ; to the 
hollow so formed the long diameter of the head accommodates itself, 
and is thus rotated into the antero-posterior diameter of the outlet. 

5. Extension. — By the process just described the face is turned 
back into the hollow of the sacrum ; but the head does not lie abso- 
lute^ in the antero-posterior diameter of the pelvic outlet, but 
rather in one between it and the oblique. The occiput is still forced 
down by the pains, and, in consequence of its altered position, is en- 
abled to pass between the rami of the pubis, and advances until its 
further descent is checked by the nape of the neck, which is pressed 
under and against the arch of the pubes. By this means the occiput 
is fixed, and, the pains continuing, the uterine force no longer acts 
on the occiput, but on the anterior part of the head, which is now 
pushed down and separated from the sternum. This constitutes 
extension. As the head descends, the soft structures of the perineum 
are stretched, and the coccyx pushed back so as to enlarge the out- 
let. The pains continue to distend the perineum more and more, 
the head advancing and receding with each pain. As the forehead 
descends, the sub-occipito-bregmatic, the sub-occipito-frontal, aud the 
sub-occipito-mental diameters successively present; the occiput turns 
more and more upwards in front of the pubes (Fig. 96), and, at last, 
the face sweeps over the perineum and is born. 

The mechanical cause of this movement may be readily explained. 



DELIVERY IN HEAD PRESENTATIONS 



263 



As soon as the occiput has passed under the arch of the pubis, and 
is no longer resisted by the anterior pelvic walls, the head is sub- 
jected to the action of two forces : that of the uterine pressure act- 
ing downwards and backwards ; and that of the resistance of the 



Fig. 96. 




First position 



posterior walls of the pelvis and the soft parts, acting almost directly 
forwards. The necessary result is that the head is pushed in a direc- 
tion intermediate between these two opposing forces — that is, down- 
wards and forwards in the axis of the pelvic outlet. 

In addition to the slight obliquity which exists as regards the 
direct relation of the long diameter of the head to the antero-poste- 
rior diameter of the outlet at the moment of its expulsion, the head 
also lies somewhat obliquely in relation to its own transverse diame- 
ter, so that, in the majority of cases, the right parietal bone is ex- 
pelled before the left. 

6. External Rotation. — Shortly after the head is expelled, as soon as 
renewed uterine action commences, it may be observed to make a 



Fig. 9 




External Rotation of Head in First Position. (After Hodge.) 

distinct rotatory movement, the occiput turning to the left thigh of 
the mother, and the face turning upward to the right thigh (Fig. 97). 
The reason of this is evident. When the head descends in the right 



264 LABOR. 

oblique diameter the shoulders lie in the opposite or left oblique diam- 
eter, and as the head rotates into the antero-posterior diameter, they 
are necessarily placed more nearly in the transverse. As soon as the 
head is expelled the shoulders are subjected to the same uterine force 
and pelvic resistance as the head has just been, and they are acted 
on in precisely the same way. Consequently they too rotate, but in 
the opposite direction, into the antero-posterior diameter of the out- 
let, or nearly so, just as the head did, and as they do so, they neces- 
sarily carry the head with them, and cause its external rotation. 

The two shoulders are soon expelled, the left shoulder generally 
the first, sweeping over the perineum in the same manner as the face. 
This is, however, not always the case, and they are often expelled 
simultaneously, or the right shoulder may come first. The body 
soon follows, and the second stage of labor is completed. 

Second Position. — In the second position (right occipito- cotyloid) 
the long diameter of the head lies in the left oblique diameter of the 
pelvis. On making a vaginal examination, in the ordinary obstetric 
position, the finger, passing upwards and to the right, feels the small 
posterior fontanelle ; downwards and to the left, it feels the anterior. 
The sagittal suture lies obliquely across the pelvis in the left oblique 
diameter. The description of the mechanism of delivery is precisely 
the same as in the first position, substituting the word left for right. 
Thus the finger impinges on the left parietal bone, the occiput turns 
from right to left during rotation. After the birth of the head the 
occiput turns to the right thigh of the mother, the face to the left 
thigh 

Third, or Right Occipito-sacro-iliac Position. — In the third position 
the head enters the pelvic brim with the occiput directed backwards 

Fig. 98. 




Third Position of Occiput, at Brim of Pelvis. 



to the right sacro-iliac synchondrosis, and the sinciput forwards to 
the left loramen ovale (Fig. 98). The posterior fontanelle is directed 



DELIVERY IN HEAD PRESENTATIONS. 265 

backwards, the anterior fontanelle forwards, while the examining 
ringer impinges on the left parietal bone. The mechanism of de- 
livery in these cases is of much interest. In the large majority of 
cases, during the progress of delivery, the occiput rotates forwards 
along the right side of the pelvis, until it comes to lie almost in the 
antero-posterior diameter of the outlet, and passes under the pubic 
arch, the forehead passing over the perineum. It will be seen that 
during part of this extensive rotation the head must lie in the second 
position, and the case terminates just as if it had been in the second 
position from the commencement of labor. 

Manner in which the Occiput is Rotated Forwards. — How is it that 
this rotation is effected, and that the sinciput, occupying the position 
of the occiput in the first position, should not be rotated forwards to 
the pubes as that is ? This, no doubt, may be explained by the fact, 
that the uterine force transmitted through the vertebral column 
causes the occiput to descend lower than the sinciput, so that in most 
cases, in making a vaginal examination, the posterior fontanelle can 
be readily felt, while the anterior is high up and out of reach. The 
head is, therefore, extremely flexed, and so descends into the pelvic 
cavity, until the occiput, being now below the right ischial spine, 
experiences the resistance of the pelvic floor, opposite the right sacro- 
ischiatic ligament, by which it is directed forwards. The forehead 
is, at this time, supposing flexion to be marked, too high to be in- 
fluenced by the anterior pelvic plane. Pressure continuing, the 
occiput rotates forwards, the forehead passes round the left side of 
the pelvis, and labor is terminated as in the second position. 

The period of labor at which rotation takes place varies. In the 
majority of cases it does not occur until the head is on the floor of 
the pelvis, for it is then that resistance is most felt; but the greater 
the resistance, the sooner will rotation be produced. Hence it is 
more likely to occur early when the head is large, and the pelvis 
comparatively small. 

The facility with which this movement is effected obviously depends 
upon the complete flexion of the chin on the sternum, by which the 
anterior fontanelle is so elevated that its rotation backwards is not 
resisted by the inward projection of the left ischial spine, and the 
occiput is correspondingly depressed. If, however, this flexion is 
not complete, and the anterior fontanelle is so low as to be readily 
within reach of the finger, considerable difficulty is likely to be 
experienced. In many such cases rotation is still eventually effected, 
but in others it is not; and the labor is then terminated with the 
face to the pubes, but at the expense of considerable delay and diffi- 
culty. According to Dr. Uvedale West, of Alford, who devoted 
much careful study to the subject, this termination occurs in about 
4 per cent, of occipito-posterior positions. When it is about to 
happen the anterior fontanelle may be felt very low down, and, 
sometimes, even the forehead and superciliary ridges. The uterine 
force pushes down the occiput, the sinciput being fixed behind the 
pubes, which it obviously cannot pass under, as does the occiput in 
the first position. The sinciput, therefore, becomes more flexed and 
18 



266 LABOR. 

pushed upwards, while the resistance of the pelvic floor directs the 
occiput forwards. The perineum now becomes enormously distended 
by the back part of the head, and is in great danger of laceration. 
The occiput is eventually, but not without much difficulty, expelled. 
A process of extension now occurs, the nape of the neck being fixed, 
as it were, against the centre of the perineum, the expelling force 
now acting on the forehead, and producing rotation of the head on 
its transverse axis. The forehead and face are thus protruded, and 
the body follows without difficulty. 

It is said that, in a few exceptional cases, where the anterior fonta- 
nelle is much depressed, the labor may terminate by the conversion 
of the presentation into one of the face, the head rotating on its 
transverse axis, the forehead passing to the posterior part of the 
pelvis, and the chin emerging under the perineum. It is obvious, 
however, that this change can only occur when the head is unusually 
small, and it must of necessity be extremely rare. 

Relative frequency of Second and Third Positions. — Reference has 
already been made to Naegele's views as to the rarity of the second 
position, and to his opinion that cases in which the occiput was found 
to point to the right foramen ovale were only transitional stages in 
the rotation of occipito-posterior positions. Such an assumption, 
however, is unwarrantable, unless the case has been watched from 
the very commencement of labor. Many perfectly qualified ob- 
servers have arrived at the conclusion that second positions are far 
more common than JSTaegele supposed; and in the table already 
quoted it will be seen that while Murphy estimates the second and 
third as being equally frequent, Swayne believes the second to be 
much more common than the third. It is probable that the weight 
of Naegele's authority has induced many observers to classify second 
positions as third positions in which partial rotation has already been 
accomplished. My own experience would certainly lead me to think 
that second positions are very far from uncommon. The question, 
however, must be considered to be in abeyance, until further ob- 
servations by competent authorities enable us to decide it conclu- 
sively. 

Fourth or Left Occipito-sacro-ischiatic. — The fourth position is just 
as much the reverse of the second as the third is of the first. The 
occiput points to the left (Fig. 99) sacro-iliac synchondrosis, and the 
finger impinges on the right parietal bone. The mechanism is pre- 
cisely the same as in the third position, the rotation taking place 
from left to right. 

Formation of the Caput Succedaneum. — The formation of the caput 
succedaneum has been already alluded to. This term is applied to 
the oeclematous swelling which forms on the head, and is produced 
by effusion from the obstruction of the venous circulation caused by 
the pressure to which the head is subjected. It follows that the size 
of the swelling is in direct proportion to the length of the labor. In 
rapid deliveries, in which the head is forced through the pelvis 
quickly, it is scarcely, if at all, developed; while, after protracted 
labors, it is large and distinct, and may obscure the diagnosis of the 



DELIVERY IN HEAD PRESENTATIONS. 267 

position, by preventing the sutures and fontanelles being felt. Its 
situation varies according to the position of the head: thus, in the 

Fig. 99. 




Fourth Position of Occiput at Pelvic Brim. 

first and fourth positions it forms on the right parietal bone, in the 
second and third on the left; and we may, therefore, verify, by 
inspection of its site, the accuracj^ of our diagnosis. 

An ordinary mistake which has been made by obstetricians is to 
regard the caput succeclaneum as formed at the point where the 
head has been most subjected to pressure ; while, in fact, it forms on 
that part which is most unsupported by the maternal structures, and 
where the swelling may consequently most readily occur. There- 
fore, in the early stages of the labor, it always forms on the part of 
the head which lies in the circle of the os uteri ; while, in. subsequent 
stages, it forms on that which lies in the axis of the vaginal canal, 
and eventually is most prominent on the part that is first expelled 
from the vulva. 

Alteration in the Shape of the Head from Moulding. — A few words 
may be said as to the alteration in the form of the foetal head which 
occurs in tedious labors, and results from the moulding which it has 
undergone in its passage through the pelvis. The smaller the pelvis, 
and the greater the pressure applied to the head during delivery, the 
more marked this is. The result is, that in vertex presentations the 
occipito-mental and occipito-frontal diameters are elongated to the 
extent of an inch, or even more, while the transverse diameters are 
lessened, from compression of the parietal bones. This moulding is 
of unquestionable value in facilitating the birth of the child. The 
amount of apparent deformity is very considerable, and may even 
give rise to some anxiety. It is well to remember, therefore, that it 
is always transient, and that in a few hours, or days at most, the 
elasticity of the soft cranial bones causes them to resume their natural 
form. The caput succedaneum also disappears rapidly, therefore no 
amount of deformity from either of these causes need give rise to 
anxiety, or call for any treatment. 



268 LABOR. 



CHAPTEE III. 

MANAGEMENT OF NATURAL LABOR, 

Although labor is a strictly physiological function, and in a large 
majority of cases, might, no doubt, be safely accomplished without 
assistance from the accoucheur, still medical aid, properly given, is 
always of value in facilitating the process, and is often absolutely 
essential for the safety of the mother and child. 

Preparatory Treatment. — The management of the pregnant woman 
before delivery is a point which should always receive the attention 
of the medical attendant, since it is of consequence that the labor 
should come on when she is in as good a state of health as possible. 
For this purpose ordinary hygienic precautions should never be 
neglected in the latter months of gestation. The patient should take 
regular and gentle exercise, short of fatigue, and, if the weather 
permit, should spend as much of her time as possible in the open air. 
Hot rooms, late hours, and excitement of all kinds should be strictly 
avoided. The diet should be simple, nutritious, and unstimulating. 
The state of the bowels should be particularly attended to. During 
the few days preceding labor the descent of the uterus often causes 
pressure on the rectum, and prevents its evacuation. Hence it is 
customary to prescribe occasional gentle aperients, such as small 
doses of castor-oil, for a few days before the expected period of de- 
livery. Some caution, however, is necessary, as it is certainly not 
very uncommon for labor to be determined rather sooner than was 
anticipated, in consequence of the irritation of too large a purgative 
dose. The state of the bowels should always be inquired into at the 
commencement of labor, and, if there be any reason to suspect that 
they are loaded, a copious enema should be administered. This is 
always a proper precaution to take, for a loaded rectum is a common 
cause of irregular and ineffective uterine action ; and even when it 
does not produce this result, the escape of the fasces, in consequence 
of pressure on the bowel during the propulsive stage, is always dis- 
agreeable both to the patient and practitioner. 

Dress of Patient during Pregnancy. — The dress of the patient dur- 
ing pregnancy may be here adverted to ; for much discomfort may 
arise, and the satisfactory progress of labor may even be interfered 
with, from errors in this respect. 

After the uterus has risen out of the pelvis the ordinary corset, 
which most women wear, is apt to produce very injurious pressure ; 
still more so when attempts are made to conceal the increased size 
by tight lacing. After the fourth or fifth month, therefore, the 
comfort of the patient is much increased by wearing a specially con- 
structed pair of stays, with elastic let into the sides and front, so that 



MANAGEMENT OF NATURAL LABOR. 269 

they accommodate themselves to the gradual increase of the figure. 
Such are made by all stay-makers, and should be worn whenever 
the circumstances of the patient permit. Failing this, it is better to 
avoid the use of the corset altogether, and to have as little pressure 
on the uterus as possible ; although many women cannot do without 
the support to which they are accustomed. To multiparas, especially 
if there be much laxity of the abdominal parietes, a well-fitting elas- 
tic abdominal belt is often a great comfort. This is constructed so 
that it can be tightened when the patient is walking and in the erect 
position, when such support is most required, and readily loosened 
when desired. 

Necessity of Attending to the First Summons. — It is hardly neces- 
sary to insist on the necessity of the practitioner attending imme- 
diately to the first summons to the patient. It is true that he may 
very often be sent for long before he is actually required. But on 

I the other hand, it is quite impossible to foresee what may be the 
state of any individual case. By prompt attention he may be able 

I to rectify a malposition, or prevent some impending catastrophe, and 
thus save his patient from consequences of the utmost gravity. 

Articles to be taken by the Accoucheur. — The practitioner should 

I always be provided with the articles which he may require. The 

' ordinary obstetric cases, containing one or two bottles and a catheter, 
such as are sold by most instrument-makers, are cumbrous and use- 
less; while "obstetric bags" are expensive luxuries not within the 
reach of all. Every one can manufacture an excellent obstetric bag 
for himself, at a small expense, by having compartments for holding 
bottles stitched on to the sides of an ordinary leather bag, such as is 
sold for a few shillings at any portmanteau-maker's. It is a great 
comfort to have at hand all that may be required, and the bag should 
contain chloroform, chloral, laudanum, the liquor ferri perchloridi of 
the Pharmacopoeia, the liquid extract of ergot, and a hypodermic 
syringe, with a bottle containing a solution of ergotine for subcuta- 
neous injection. If it also contain a Higginson's syringe, a small 
elastic catheter, a good pair of forceps, and one or two suture needles, 
with some silver wire or carbolized catgut, the practitioner is pro- 
vided against any ordinary contingency. Other articles that may 
be required, such as thread, scissors, and the like, are generally pro- 
vided by the nurse or patient. 

Duties on first Visiting the Patient. — On arriving at the house the 
practitioner should have his visit announced to the patient, and he 
will very often find that the first effect of his presence is to arrest 
the pains that have been hitherto progressing rapidly ; thereby af- 
fording a very conclusive proof of the influence of mental impres- 
sions on the progress of labor. If the pains be not already propulsive, 
it is well that he should occupy himself at first in general inquiries 
from the attendants as to the progress of the labor, and in seeing 
that all the necessary arrangements are satisfactorily carried out, so 
as to allow the patient time to get accustomed to his presence. If 
he have any choice in the matter, he should endeavor to secure a 
large, airy, and well-ventilated apartment for the lying-in room, as 



270 LABOR. 

far removed as possible from without. He may also see to the bed, 
which should be without curtains, and prepared for the labor by 
having a water-proof sheeting laid under a folded blanket or sheet, 
on which the patient lies. These receive the discharges during la- 
bor, and can be pulled from under the patient after delivery, so as 
to leave the dry clothes beneath. Among the lower classes, the 
lying-in chamber is considered a legitimate meeting-place for nu- 
merous female friends to gossip, whose conversation is often distress- 
ing, and is certainly injurious, to a woman in the excitable condition 
associated with labor. The medical attendant should, therefore, insist 
on as much quiet as possible, and should allow no one in the room 
except the nurse and some one friend whose presence the patient 
may desire. The husband's presence must be left to the wishes of 
the patient. Some women like their husbands to be with them, while 
others prefer to be without them, and the medical attendant is bound 
to act in accordance with the patient's desire. 

Vaginal Examination. — If pains be actually present a vaginal ex- 
amination is essential, and should not be delayed. It enables us to 
ascertain whether the labor has commenced or not, and whether the 
presentation is natural or otherwise. The pains, although apparently 
severe, may be altogether spurious, and labor may not have actually 
commenced. It is of much importance, both for our own credit and 
comfort, that we should be able to diagnose the true character of the 
pains; for if they be so-called "false" pains, we might wait hours 
in fruitless expectation of progress, while delivery is still far off. 
The necessity of ascertaining, therefore, the actual state of affairs need 
not further be insisted on. 

Character of False Pains. — False pains are chiefly characterized by 
their irregularity, sometimes coming on at short intervals, sometimes 
with many hours between them ; they also vary much in intensity, 
some being very sharp and painful, while others are slight and tran- 
sient. In these respects they differ from the true pains of the first stage, 
which are at first slight and short, and gradually recur with in- 
creased force and regularity. The situation of the two kinds of pains 
also varies, the false pains being chiefly situated in front, while the 
true pains are most felt in the back, and gradually shoot round to- 
wards the abdomen. Nothing short of a vaginal examination will 
enable us to clear up the diagnosis satisfactorily. If the labor have 
actually commenced, the os will be more or less dilated, and its edges 
thinned ; while with each pain the cervix will become rigid, and the 
membranes tense and prominent. The false pains, on the contrary, 
have no effect on the cervix, which remains flaccid and undilated ; 
or, if the os be sufficiently open to admit the tip of the finger, the 
membranes will not become prominent during the contraction. Un- 
der such circumstances we may confidently assure the patient that 
the pains are false, and measures should be taken to remove the irri- 
tation which produces them. In the large majority of cases the cause 
of the spurious pains will be found to be some disordered state of 
the intestinal tract ; and they will be best remedied by a gentle ape- 
rient — such as castor-oil, or the compound colocynth pill with hyos- 



MANAGEMENT OF NATURAL LABOR. 271 

cvamus — followed by, or combined with, a sedative, such as twenty 
minims of laudanum or chlorodyne. Shortly after this has been 
administered the false pains will die away, and not recur until true 
labor commences. 

Mode of conducting a Vaginal Examination. — For a vaginal exami- 
nation the patient is placed by the nurse on her left side, close to the 
edge of the bed, with the legs flexed on the abdomen. The prac- 
titioner, being seated by the edge of the bed, passes the index finger 
of the right hand, previously lubricated with lard or cold cream, up 
to the vulva, and gently insinuates it into the orifice of the vagina, 
then pushes it backwards in the axis of the vaginal outlet, and 
finally turns it upwards and forwards so as to more readily reach the 
cervix. This it may not always be easy to do, for at the commence- 
ment of labor the cervix may be so high as to be reached with dif- 
ficulty, or it may be directed backwards so as to point towards the 
cavity of the sacrum. The exploration is often much facilitated by 
depressing the uterus from without, by the left hand placed on the 
abdomen. Our object is not only to ascertain the state of the cervix 
as to softness and dilatation, but also the presentation, the condition 
of the vagina, and the capacity of the pelvis. The examination is 
generally commenced during a pain, at which time it is less distress- 
ing to the patient ; but in order to be satisfactory, the finger must 
remain in the vagina until the pain is over, the examination being 
concluded in the interval between this pain and the next. 

In head presentations the round mass of the cranium is generally 
at once felt through the lower part of the uterus, and then we have 
the satisfaction of being able to assure the patient that all is right. 
If the os be sufficiently dilated, we can also feel through it the occi- 
put covered by the membranes. It is impossible at this time to 
make out the exact position of the head by means of the sutures and 
fontanelles, which are too high up to be within reach. Nor should 
any attempt be made to do so, for fear of prematurely rupturing the 
membranes. The fact that the head is presenting is all that we 
require to know at this stage of the labor. 

Hie Condition of the Os as indicating the Progress of Lahor. — The 
condition of the os itself, as to rigidity and dilatation, will materially 
assist us in forming an opinion as to the progress and probable dura- 
tion of the labor; but, although the friends will certainly press for 
an opinion on this point, the cautious practitioner will be careful not 
to commit himself to a positive statement, which may so easily be 
falsified. It will suffice to assure the friends that everything is satis- 
factory, but that it is impossible to say with any certainty how 
rapidly, or the reverse, the case may progress. 

If the pains be not very frequent or strong, and the os not dilated 
to more than the size of a shilling, a considerable delay may be antici- 
pated, and the presence of the medical attendant is useless. He 
may, therefore, safely leave the patient for an hour or more, provided 
he be within easy reach. It is needless to say that this should never 
be done unless the exact presentation be made out. If some part, 
other than the head, be presenting, it will probably be impossible to 



272 



LABOR, 



make it out until dilatation has progressed further ; and the prac- 
titioner must be incessantly on the watch until the nature of the case 
be made out, so as to be able to seize the most favorable moment for 
interference, should that be necessary. 

Position of Patient daring First Stage. — The position of the patient 
is a matter of some moment in the first stage. It is a decided ad- 
vantage that she should not be then in a recumbent position on her 
side, as is usual in the second stage ; for it is of importance that the 
expulsive force should act in such a way as to favor the descent ot 
the head into the pelvis, i. e., perpendicularly to the plane of its brim, 
and also that the weight of the child should operate in the same way. 
Therefore, the ordinary custom of allowing the patient to walk 



Fig. 100. 




Examination during the first stage. 

about, or to recline in a chair, is decidedly advantageous ; and it will 
often be observed that the pains are more lingering and ineffective if 
she lie in bed. If the patient be a multipara, or if the abdomen be 
somewhat pendulous, an abdominal bandage, by supporting the 
uterus, will greatly favor the progress of this stage. Keeping the 
patient out of bed has the further advantage of preventing her be- 
ing unduly anxious for the termination of the labor ; and a little 
cheerful conversation will keep up her spirits, and obviate the mental 
depression which is so common. Good beef-tea may be freely ad- 
ministered, with a little brandy and water occasionally, if the patient 
be weak, and will be useful in supporting her strength. 

Vaginal Examinations. — Over-frequent vaginal examinations at 
this period should be avoided, for they serve no useful purpose, and 



MANAGEMENT OF NATURAL LABOR. 273 

are apt to irritate the cervix. It will be necessary, however, to as- 
certain the progress of the dilatation at intervals. 

Artificial Rupture of the Membranes . — When once the os is fully di- 
lated the membranes may be artificially ruptured if they have not 
broken spontaneously, for they no longer serve any useful purpose, 
and only retard the advent of the propulsive stage. This can be 
easily done by pressing on them, when they are rendered tense dur- 
ing a pain, by some pointed instrument, such as the end of a hair- 
pin, which is always at hand. In some cases, indeed, it is even 
expedient to rupture the membranes before the os is fully dilated. 
Thus it not infrequently happens, when the amount of liquor amnii 
is at all excessive, that the os dilates to the size of a five -shilling- 
piece or more ; but, although it is perfectly soft and flaccid, it opens 
up no further until the liquor amnii is evacuated, when the propul- 
sive pains rapidly complete its dilatation. Some experience and 
judgment are required in the detection of such cases, for if we evacu- 
ated the liquor amnii prematurely the pressure of the head on the 
cervix might produce irritation, and seriously prolong the labor. 
This manoeuvre is most likely to be useful when the pains are strong 
and the os perfectly flaccid, but when the membranes do not protrude 
through the os and effect further dilatation. 

It is sometimes not easy to ascertain whether the membranes are 
ruptured or not. This is most likely to be the case when the head 
is low down, and the amount of liquor amnii is so small that the 
pouch does not become prominent during the pains. A little care, 
however, will enable us, if the membranes be ruptured, to feel the 
rugosities of the scalp covered with hair, and to distinguish it from 
the smooth polished surface of the membranes. 

Treatment of the Propulsive Stage. — After the evacuation of the 
liquor amnii there is generally a lull in the progress of the labor, the 
pains, however, soon recurring with increased force and frequency, 
and propelling the head through the pelvic cavity. The change in 
the character of the pains is soon appreciated by the bearing down 
efforts by which they are accompanied, as well as by their increased 
length and intensity. 

Position of the Patient during the Second Stage. — Tt is now advisa- 
ble that the patient be placed in bed ; and in this country it is usual 
for her to lie on her left side, with her nates parallel to the edge of 
the bed, and her body lying across it, This is the established ob- 
stetric position in England, and it would be useless to attempt to in- 
sist on any other, even if it were advisable. Although the dorsal 
position is preferred on the Continent and in America, 1 it is difficult 
to see wherein its advantages consist. It certainly leads to unneces- 
sary exposure of the person, and it is, on the whole, less easy to 
reach the patient, so placed, for the necessary manipulations. More- 
over, the dorsal position increases the risk of laceration of the peri- 
ls 1 In the United States, the dorsal position is rarely used, except where forceps are 
applied, craniotomy is resorted to, or the uterus is much anteverted. In ordinary 
labors, the woman is placed on her left side, as in England. — Ed.] 



271 LABOR. 

neum, by bringing the weight of the child's head to bear more 
directly upon it. Thus Schroeder found that lacerations occurred in 
37.6 per cent, of cases delivered on the back, as against 24.4 per 
cent, in other positions. 

The patient usually remains in bed during the whole of this stage, 
and it is customary for the nurse to tie to the foot of the bed a jack- 
towel, which is laid hold of and used as a support in making bearing 
down efforts. If the pains be few and far between, and the patient 
finds it more comfortable to get up occasionally, there is no reason 
why she should not do so. On the contrary, as we shall subsequently 
see in treating of lingering labor, the pains under such circumstances 
are often increased in the sitting posture, in consequence of the 
weight of the child producing increased pressure on the nerves of 
the vagina. 

Detection of the Position of the Head. — At this time vaginal exami- 
nation, which should be more frequently repeated than in the first 
stage, enables us to ascertain precisely the position of the head, by 
means of the sutures and fontanelles, as well as to watch its progress. 

Management of the Anterior Lip of Cervix when impacted between 
the Head and Pelvis. — It not infrequently happens that the head 
descends into the pelvis, even to its floor, without the os having 
entirely disappeared. The anterior lip especially is apt to get caught 
between the head and pubis, to become swollen by the pressure to 
which it is subjected, and then to retard the progress of the labor. 
There can be no reasonable objection to attempting to prevent this 
cause of delay by pressing on the incarcerated lip during the inter- 
val of the pains, so as to push it above the head, and maintain it 
there during the pains, until the head descends below it. This 
manoeuvre, if done judiciously, and without any undue roughness or 
force, is certainly not liable to be attended by any of the evil con- 
sequences which many obstetricians have attributed to it; it is 
indeed a matter of common sense that the injury to the cervix is 
likely to be less if it be pushed gently out of the way, than if it be 
left to be tightly jammed for hours between the presenting part and 
the bony pelvis. This mode of assistance is very different from the 
digital dilatation of a rigid cervix, which was formerly much prac- 
tised, especially in Edinburgh, in consequence of the recommendation 
of Hamilton, and which was properly objected to by the great ma- 
jority of obstetricians. 

If the pains be producing satisfactory progress, no further interfe- 
rence is required. The medical attendant should, however, see that 
the bladder is evacuated; and if it have not been so for some hours, 
it may be necessary to draw off the urine by the catheter. When- 
ever the labor is lengthy, he should occasionally practise auscultation, 
so as to satisfy himself that the foetal circulation is being satisfactorily 
carried on. 

Regulation of the Voluntary Bearing-down Efforts. — The regulation 
of the bearing-down efforts at this time is of importance. It is com- 
mon for the nurse to urge the patient to help herself by straining, 
and it is certain that by voluntary exertion of this kind she can 



MANAGEMENT OF NATURAL LABOR. ZTD 

materially increase the action of the accessory muscles of parturition. 
If the pains be strong, and the labor promise to be rapid, such 
voluntary exertions are not likely to be prejudicial. On the other 
hand, if the case be progressing slowly, they only unnecessarily 
fatigue the patient, and should be discouraged. When the perineum 
is distended we may even find it advisable to urge the patient to 
cease all voluntary effort, and to cry out, for the express purpose of 
lessening the tension to which the perineum is subjected. This is 
the stage in which anaesthesia is most serviceable, but its employment 
must be separately discussed. 

Distension of the Perineum. — As the head descends more and more 
the perineum becomes distended, and there is considerable difference 
of opinion amongst accoucheurs as to the management of the case 
at this time. In most obstetric works the practitioner is advised to 
endeavor to prevent laceration by the manoeuvre that is described 
as '-supporting the perineum." By this is meant, laying the palm 
of the hand on the distended structures, and pressing firmly upon 
them during the acme of the pain, with the view of mechanically 
preventing their tearing. There can be little doubt that this, or 
some modification of it, is the practice now followed by the large 
majority of practitioners. Of late years the evil effects likely to 
follow it have been specially dwelt upon by Graily Hewitt, Leishman, 
Groodell, and other writers, who maintain that hj pressure exerted in 
this fashion we not only fail to prevent, but actually favor laceration, 
in consequence of the pressure producing increased uterine action, 
just at the time when forcible distension of the perineum is likely to 
be hurtful. Therefore some hold that the perineum ought to be left 
entirely alone, and that the head should be allowed gradually to dis- 
tend it, without any assistance on the part of the practitioner. 

Much error may be traced to a misconception of what is required. 
The term "supporting the perineum" conveys an unquestionably 
erroneous idea, and it is certain that no one can prevent laceration 
by mechanical support. If the term "relaxation of the perineum" 
were employed, we should have a far more accurate idea of what 
should be aimed at, and if this be borne in mind, I think it cannot 
be questioned that nature may be most usefully assisted at this 
stage. 

Dr. GoodelTs Method. — Dr. Goodell, of Philadelphia, has specially 
studied this subject, and has recommended a method, the object of 
which is to relax the perineum. His advice is, that one or two 
fingers of the left hand should be inserted into the rectum, by which 
the perineum should be hooked up and pulled forward over the head, 
towards the pubis, the thumb of the same hand being placed on the 
advancing head, so as to restrain its progress if needful. I have 
adopted this plan frequently, and believe that it admirably answers 
its purpose, especially when the perineum is greatly distended, and 
laceration is threatened. It must be admitted that the insertion of 
the fingers into the anal orifice, in the manner recommended, is re- 
pugnant both to the practitioner and patient, and the same result 
can be obtained in a less unpleasant way. I mention it, however, to 



276 



LABOR, 



show what it is that the practitioner must aim at. If, when the head 
is distending the perineum greatly, the thumb and forefinger of the 
right hand are placed along its sides, it can be pushed gently forward 
over the head at the height of the pain, while the tips of the fingers 
may, at the same time, press upon the advancing vertex, so as to 
retard its progress if advisable (Fig. 101). By this means the sud- 

Fig. 101. 




I n nit 

Mode of effecting relaxation of the Perineum. 

den and forcible stretching of the perineal structures is prevented, 
and the chance of laceration reduced to a minimum, while nature's 
mode of relaxing the tissues, by dilatation of the anal orifice, is 
favored. This is very different from the mechanical support that is 
usually recommended, and the less pressure that is applied directly 
to the perineum the better. Nor is it either needful or advisable to 
sit by the patient with the hand applied to the perineum for hours, 
as is so often practised. Time should be given for the gradual dis- 
tension of the tissues by the alternate advance and recession of the 
head, and we need only intervene to assist relaxation when the 
stretching has reached its height, and the head is about to be ex- 
pelled. A napkin may be interposed between the hand and the skin, 
for the purpose of cleanliness. Should the perineum be excessively 
tough and resistant, assiduous fomentation with a hot sponge may 
be resorted to, and will be of some service in promoting relaxation. 
Incision of the Perineum. — When the tension is so great that lace- 
ration seems inevitable, it is generally recommended that a slight 
incision should be made on each side of the central raphe!, with the 
view of preventing spontaneous laceration. This may no doubt be 
done with perfect safety, but I question if it is likely to be of use. 
The idea is that an incised wound is likely to heal more readily than 
a lacerated one. When, however, a distended perineum ruptures, its 



MANAGEMENT OF NATURAL LABOR. 277 

structures are so thinned that the tear is always linear ; and, as a 
matter of fact, the edges of the tear are always as clean, and as 
closely in apposition, as if the cut bad been made with a knife. 
Moreover, the laceration invariably heals perfectly, if only the edges 
be brought into contact at once with one or two metallic sutures. I 
believe, therefore, that Groodell is right in stating that incision of the 
perineum is rarely, if ever, necessary, unless it is hardened by pre- 
vious cicatrization. In almost all first labors, the fourchette is torn, 
but requires no treatment of any kind. In some cases, do what we 
will, more or less laceration occurs, and the perineum should always 
be examined after the expulsion of the child, to see if any tear has 
taken place. 

Treatment of Lacerations. — If it has given way to any extent, I 
believe that it is good practice to insert one or two mterrrupted su- 
tures of silver wire or carbolized gut at once. Immediately after 
delivery the sensibility of the tissues is deadened by the distension 
to which they have been subjected, and the sutures can be inserted 
with little or no pain. It is quite true that lacerations of an inch or 
less will generally heal perfectly well of themselves ; but this is not 
invariably the case, while healing almost certainly follows if the 
edges be brought together at once. In the severer forms of lacera- 
tion, extending back to, or even through the sphincter, the precaution 
is all the more necessary, and a subsequent operation of gravity may 
in this way be avoided. The sutures can be removed without diffi- 
culty in a week or so, when complete adhesion has taken place. 

Expulsion of the Child. — The head, when expelled, should be re- 
ceived in the palm of the right hand, while the left hand is placed 
upon the abdomen to follow down the uterus as it contracts and 
expels the body. There is generally some little delay after the ex- 
pulsion of the head, and we should now see if the cord surround the 
neck, and, if it does so, it should be drawn over the head. The ex- 
pulsion of the body should be left entirely to the uterine contrac- 
tions. If there be undue delay we may endeavor to excite uterine 
action by friction on the fundus, and it will rarely happen that 
sufficient contraction does not now come on. If we display undue 
haste in withdrawing the body, we run the risk of emptying the 
uterus while its tissues are relaxed, and so favor hemorrhage. If, 
however, there seem serious danger of the child being asphyxiated, 
its expulsion may be favored by gently passing the forefinger of each 
hand within the axillae, and using traction ; but it is only very 
exceptionally that such interference is required. 

Promotion of Uterine Contraction after the Birth of the Child. — As 
the uterus contracts, it should be carefully followed down through 
the abdominal parietes by the left hand, which should grasp it as the 
body is expelled, with the view of seeing that it is efficiently con- 
tracted. This is a point of vital importance in preventing hemorrhage, 
which will presently be more especially considered. 

Ligature of the Cord. — As soon as the child cries we may proceed 
to tie and separate the cord. For this purpose the nurse usualljr 
provides ligatures composed of several strands of whitey-brown 



278 LABOR. 

thread ; but tape, or any other suitable material, may be employed. 
It is important, especially if the cord be very thick and gelatinous, 
to see that it is thoroughly compressed, so that the vessels are ob- 
literated, otherwise secondary hemorrhage might occur. The cord 
is tied about an inch and a half from the child, and it is usual, though 
of course not essential, to place a second ligature about two inches 
nearer the placental extremity of the cord. The latter is, perhaps, 
of some use by retaining the blood, and thus increasing the size of, 
the placenta, and favoring its more ready expulsion by uterine con- 
traction. The cord is then divided with scissors between the liga- 
tures, the child wrapped up in flannel, and given to the nurse, or a 
bystander, to hold, while the attention of the practitioner is concen- 
trated on the mother, with a view to the proper management of the 
third stage of labor. 

Importance of Proper Management of Third Stage. — There is un- 
questionably no period of labor where skilled management is more 
important, and none in which mistakes are more frequently made. 
By proper care at this time the risk of post-partum hemorrhage is 
reduced to a minimum, the efficient contraction of the uterus is 
secured, the amount and intensity of after-pains are lessened, and the 
safety and comfort of the patient greatly promoted. Moreover, the 
general practice, as to the management of this stage, is opposed to 
the natural mechanism of placental expulsion, and is far from being 
well adapted to secure the important objects which we ought to have 
in view. Let us see what is the practice usually recommended and 
followed, and then we shall be in a position to understand in what 
respects it is erroneous. For this purpose I cannot do better than 
copy the directions contained in one of our most deserved^ popular 
obstetric text-books, which undoubtedly expresses the usual practice 
in the management of this stage. " When the binder is applied, the 
patient may be allowed to rest a while, if there is no flooding ; after 
which, when the uterus contracts, gentle traction may be made by the 
funis, to ascertain if the placenta be detached. If so, and especially 
if it be in the vagina, it may be removed by continuing the traction 
steadily in the axis of the upper outlet at first, at the same time 
making pressure on the uterus." 1 . 

Objections to Ordinary Practice. — This may fairly be taken as a 
sufficiently accurate description of the practice usually followed. 2 
The objections I have to make are: (1) That it inculcates the 
common error of relying on the binder as a means of promoting 
uterine contraction, advising its application before the expulsion of 
the placenta ; while I hold that the binder should never be applied 
until after the placenta is expelled, and not even then, unless the 
uterus is perfectly and permanently contracted. (2) That it teaches 
that traction on the cord should be used as a means of withdraw- 
ing the placenta ; whereas the uterus itself should be made to expel 
the after-birth, and, in nineteen cases out of twenty, the finger need 

1 Churchill's Theory and Practice of Midwifery, p. 162. 

2 This practice is further illustrated by the annexed diagram, contained in most 



MANAGEMENT OF NATURAL LABOR. ZiV 

never be introduced into the vagina after the birth of the child, nor 
the cord touched. This may seem an exaggerated statement to those 
who have accustomed themselves to the usual method of dealing with 
the placenta ; but I feel confident that all who have learnt the method 
of expression of the placenta would testify to its accuracy. 

Expression of the Placenta. — The cardinal point to bear in mind is,' 
that the placenta should be expelled from the uterus by a vis a terg.o, 
not drawn out by a vis a fronte. That uterine pressure after the 
birth of the child has been recommended by many English writers 
is certain, and the Dublin school especially have dwelt on its import- 
ance as a preventive of post-partum hemorrhage ; but the distinct 
enunciation of the doctrine that the placenta should be pressed, and 
not drawn, out of the uterus, we owe to Crecle and other German 
writers ; and it is only of late years that this practice has become at 
all common. Those who have not seen placental expression prac- 
tised, find it difficult to understand that, in the large majority of 
cases, the uterus may be made to expel the placenta out of the va- 
gina; but such is unquestionably the fact, A little practice is no 
doubt necessary to effect this satisfactory ; but when once the 
knack has been learnt, there is little difficulty likely to be ex- 
perienced. 

Importance of not Removing the Placenta Hurriedly . — Before de- 
scribing the method of placental expression, a word of caution may 
be said against undue haste in attempting expression of the placenta, 
a mistake that is often made, and which, I believe, tends to increase 

obstetric works, -which represents the accoucheur as withdrawing the placenta by trac- 
tion, and which I insert as an illustration of what ought not to be done (Fig, 102). 

Fig. 102. 




Usual Method of Removing the Placenta by Traction on the Cord. 



280 LABOR. 

the risk of post-partum hemorrhage. So long as we satisfy ourselves 
that the uterus is fairly contracted, so as to avoid the possibility of 
its distension with blood, a certain delay after the birth of the child 
is useful, from its giving time for coagula to form within the uterine 
sinuses, by which their open mouths are closed up. The importance 
of this point has been specially dwelt upon by M'Clintock, who lays 
down the rule that 15 or 20 minutes should be allowed to elapse, 
after the birth of the child, before any attempt to remove. the after- 
birth is made. This is a good and safe practical rule, as it gives 
ample time for the complete detachment of the placenta, and the co- 
agulation of the blood in the uterine sinuses. 

Mode of Effecting Expression of the Placenta. — During this inter- 
val the practitioner or nurse should sit by the bedside, with the hand 
on the uterus to secure contraction and prevent distension ; but not 
kneading or forcibly compressing it. When we judge that a suffi- 
cient time has elapsed, we may proceed to effect expulsion. For 
this purpose the fundus should be grasped in the hollow of the left 
hand, the ulnar edge of the hand being well pressed down behind 
the fundus, and when the uterus is felt to harden, strong and firm pres- 
sure should be made downwards and backwards in the axis of the 
pelvic brim. If this manoeuvre be properly carried out, and suffi- 
ciently firm pressure made, in almost every case the uterus may be 
made to expel the placenta into the bed, along with any coagula that 
may be in its cavity (Fig. 103). The uterine surface of the pla- 

Fig. 103. 




Illustrating Expression of the Placenta. 

centa is generally expelled first, as is represented in the diagram, the 
cord being within the membranes; whereas the foetal surface, and 
root of the cord, are the parts which appear first when the placenta 
is removed by traction (Fig. 102). If we do not succeed at the first 
effort, which is rarely the case if extrusion be not attempted too 
soon after the birth of the child, we may wait until another contrac- 



MANAGEMENT OF NATURAL LABOR. 281 

tion takes place, and then reapply the pressure. I repeat that, after 
a little practice, the placenta may be entirely expelled in this way, 
in nineteen cases out of twenty, without even touching the cord, 
and the bugbear of retained placenta will cease to be a source of 
dread. 

Management of the Membranes. — Should we fail in causing the 
uterus to expel the placenta, a vaginal examination may be made, 
and, if the placenta be found lying entirely in the vagina, it may be 
carefully withdrawn. If, however, the cord can be traced up through 
the os, showing that the placenta is still within the uterine cavity, 
we must again resort to pressure to effect its expulsion, and not at- 
tempt to withdraw it by traction. Such cases may fairly be classed 
as retained placenta, but they should be very rarely met with, and 
are discussed elsewhere. When they do occur often in the hands of 
the same practitioner, it is fair to conclude that he has not properly 
acquired the art of managing this stage of labor. Generally speak- 
ing, the placenta should be expelled within twenty minutes after the 
birth of the child ; but no doubt, in the large majority of cases, 
expulsion might be effected sooner were it advisable to attempt it. 

When the mass of the placenta is expelled, the membranes gen- 
erally still remain in the vagina, and they should be twisted into a 
rope, and very gently withdrawn, so as not to leave any portion be- 
hind. The risk of this accident will be lessened if the placenta is 
received into the palm of the right hand, on expression, so as to 
avoid any strain on the membranes. 

Compression of the Uterus after the Expulsion of the Placenta. — The 
duties of the medical attendant are not even now over. For at least 
ten minutes after the extrusion of the placenta, he should keep his 
hand on the firmly contracted uterus, gently kneading it, without 
any force, for the purpose of promoting firm and equable contraction, 
and causing it to throw off any coagula that may form in its cavity. 

Administration of Ergot of Rye. — The subsequent comfort and safety 
of the patient may be promoted by administering, at this time, a full 
dose of ergot of rye, such as a drachm, or more, of the liquid extract. 
The property possessed by this drug of producing tonic and persistent 
contraction of the uterine fibres, which renders it of doubtful utility 
as an oxytocic during labor, is of special value after delivery, when 
such contraction is precisely what we desire. I have long been in 
the habit of administering the drug at this period, and believe it to 
be of great value, not only as a prophylactic against hemorrhage, 
but as a means of lessening after-pains. 

Application of the Binder. — When we are satisfied that the uterus 
is permanently contracted we may apply the binder, but this should 
rarely be clone until at least half an hour after the birth of the child. 
The soiled clothes should be gently withdrawn from under the 
patient, moving her as little as possible, and the binder should be, 
at the same time, slipped under the body, taking care that it is 
passed well below the hips, so as to secure a firm hold. No kind of 
bandage is better than a piece of stout jean, of sufficient breadth to 
extend from the trochanters to the ensiform cartilage ; a jack-towel 
19 



282 LABOR. 

or bolster slip answers the purpose very well. These are preferable, 
at any rate at first, to the shaped binders that are often used. One 
or two folded napkins are generally placed over the uterus, so as to 
form a pad to keep up pressure. Once in position, the binder is 
pulled tight, and fastened by pins. The utility of careful bandaging 
after delivery can scarcely be doubted, although some years ago it 
became the fashion to dispense with it. It gives a comfortable sup- 
port to the lax abdominal walls, keeps up a certain amount of pres- 
sure on the uterus, and tends to restore the figure of the patient. 
After the bandage is applied, a warm napkin should be placed on the 
vulva, as a means of estimating the quantity of the discharge, and 
the patient may be allowed to rest. 

After-treatment. — Unless the labor have been very long and fatigu- 
ing, an opiate, often exhibited as a matter of routine, is unadvisable ; 
although it may be well to leave one with the nurse, to be given if 
the patient cannot sleep, or if the after-pains be very troublesome'. 
The practitioner may now leave the room, but not the house, and at 
least an hour should elapse after delivery before he takes his depart- 
ure. Before doing so he should visit the patient, inspect the napkin 
to see that there is not too much discharge, and satisfy himself 
that the uterus is contracted, and not distended with coagula. He 
should also count the pulse, which, if the patient be progressing 
satisfactorily, will be found at its normal average. If, however, it 
be beating over 100 per minute, he should on no account leave, for 
such a rapidity of the circulation renders it extremely probable that 
hemorrhage is impending. This is a good practical rule, laid down 
by M'Clintock in his excellent paper " On the Pulse in Child-bed," 
attention to which may often save the patient from disastrous con- 
sequences. 

Before leaving, the practitioner should see that the room is dark- 
ened, all bystanders excluded, and the patient left as quiet as possible 
to recover from the shock of labor. 



CHAPTER IY. 

ANAESTHESIA IN LABOR. 

A FEW words may be said as to the use of anaesthetics during 
labor, a practice which has become so universal that no argument is 
required to establish its being a perfectly legitimate means of as- 
suaging the sufferings of childbirth.. Indeed, the tendency in the 
present day is in the opposite direction ; and a common error is the 
administration of chloroform to an extent which materially interferes 



ANESTHESIA IN LABOR. 283 

with the uterine contractions, and predisposes to subsequent post- 
partum hemorrhage. 

Agents Employed. — Practically speaking, the only agent employed 
in this country is chloroform, although the bi-chloride of methylene, 
and ether, have been occasionally tried. Of late years, chloral has 
been extensively used by some ; and as I believe it to be an agent 
of very great value, I shall first indicate the circumstances under 
which it may be employed. 

Chloral. — The peculiar value of chloral in labor is, that it may be 
safely administered at a time when chloroform cannot be generally 
employed. The latter, while it annuls suffering, very frequently 
tends, in a marked degree, to diminish uterine action. This is a 
familiar observation to all who have employed it much during labor, 
as the diminution of the force and intensity of the pains, and the 
consequent retardation of the labor, often oblige us to suspend its in- 
halation, at least temporarily. Indeed, this very property of annul- 
ling uterine action is one of its most valuable qualities in obstetrics, 
as in certain cases of turning. For such purposes it is necessary to 
give it to the surgical extent, which we endeavor to avoid when it is 
used simply to lessen the suffering of ordinary labor. Still it is not 
always easy to limit its action in this way, and thus it very frequently 
does more than we wish. Such diminution in the intensity of uterine 
contraction is comparatively of less consequence in the propulsive 
stage, and it is generally more than counterbalanced by the relief it 
affords. In the first stage it is otherwise, and, practically speaking, 
chloroform is generally not admissible until the head is in the pelvic 
cavity. 

Chloral on the other hand, has no such relaxing effects on uterine 
contraction. It cannot, it is true, compete with chloroform in its power 
of relieving pain, but it produces a drowsy state in which the pain is 
not felt nearly so acutely as before. It is, therefore, in the first stage 
of labor, while the pains are cutting and grinding, and during the 
dilatation of the cervix, that it finds its most useful application. It 
is especially valuable in those cases, so frequently met with in the 
upper classes, in which the pains produce intolerably acute suffering, 
with but little effect on the progress of the labor. In them the os is- 
often thin and rigid, and the pains very frequent and acute, but little 
or no dilatation is effected. When the patient is brought under the 
influence of chloral, however, the pains become less frequent but 
stronger, nervous excitement is calmed, and the dilatation of the 
cervix often proceeds rapidly and satisfactorily. Indeed, I know of 
nothing which answers so well in cases of rigid, undilatable cervix, 
and I believe its administration to be far more effective, under such 
circumstances, than any of the remedies usually employed. 

Object and Mode of Administration. — The object is to produce a 
somnolent condition, which shall be protracted as long as possible. 
For this purpose 15 grains of chloral may be administered every 
twenty minutes, until three doses are given. This generally suffices' 
to produce the desired effect. The patient becomes very drowsy,. 
clozes between the pains, and wakes up as each contraction com- 



284 LABOR. 

mences. It may be necessary to give a fourth, close, at a longer in- 
terval, say an hour after the third dose, to keep up and prolong the 
soporific action, but this is seldom necessary, and I have rarely given 
more than a drachm of chloral during the entire progress of labor. 
Another advantage of this treatment is that, while it does not inter- 
fere with the use of chloroform in the second stage, it renders it 
necessary to give less than otherwise would be called for, and thus 
its action can be more easily kept within bounds. On the whole, 
therefore, I am inclined to consider chloral a very valuable aid in the 
management of labor, and believe that it is destined to be much more 
extensively used than is at present the case. So far as my experi- 
ence has yet gone I have not met with any symptoms Avhich have led 
me to think that it has produced bad effects ; and I have known 
many patients sleep quietly through labor, without expressing any 
excessive suffering, or asking for chloroform, who, under ordinary 
circumstances, w r ould have been most urgently calling for relief. 

Chloroform. — Generally speaking, we do not think of giving chloro- 
form until the os is fully dilated, the head descending, and the pains 
becoming propulsive. It has often, indeed, been administered earlier, 
for the purpose of aiding the dilatation of a rigid cervix, and there 
is no doubt that it often succeeds well when employed in this way ; 
but I have already stated my belief that chloral answers this purpose 
better. 

Should only be given during the Pains. — There is one cardinal 
rule to be remembered in giving chloroform during the propulsive 
stage, and that is, that it should be administered intermittently, and 
never continuously. When the pain comes on a few drops may be 
scattered over a Skinner's inhaler, which affords one of the best 
means of administering it in labor, or placed within the folds of a 
handkerchief twisted into the form of a cone. During the acme of 
the pain the patient inhales it freely, and at once experiences a sense 
of great relief; and, as soon as the pain dies away, the inhaler should 
be removed. In the interval between the pains the effect of the drug 
passes off, so that the higher degree of anaesthesia should never be 
produced. Indeed, when properly given, consciousness should not 
be entirely abolished, and the patient, between the pains, should be 
able to speak, and understand what is said to her. This intermittent 
administration constitutes the peculiar safety of chloroform admin- 
istered in labor, and it is a fortunate circumstance that, as yet, there 
is, I believe, no case on record of death during the inhalation of 
chloroform for obstetric purposes. This is obviously due to the 
effect of each inhalation passing off before a fresh dose is admin- 
istered. 

The effect on the pains should be carefully watched. If they 
become very materially lessened in force and frequency, it may be 
necessary to stop the inhalation for a short time, commencing again 
when the pains get stronger, which effect may be often completely 
and easily prevented by mixing the chloroform with about one-third 
of absolute alcohol, which, originally recommended, I believe, by 
Dr. Sansom, increases the stimulating effects of the chloroform, and 



AXiESTHESIA IN LABOR. 285 

thus diminishes its tendency to produce undue relaxation. The 
amount administered must vary, of course, with the peculiarities of 
each individual case and the effect produced, but it need never be 
large. As the head distends the perineum, and the pains get very 
strong and forcing, it may be given more freely and to the extent of 
inducing even complete insensibility just before the child is born. 

Ether as a Substitute for Chloroform. — In cases in which chloroform 
has lessened the force of the pains, I have, of late, frequently sub- 
stituted the inhalation of ether with great advantage. It certainly 
often acts well when chloroform is inadmissible on account of its 
effects on the pains, and, so far as my experience goes, it has not the 
property of relaxing the uterus, but, on the contrary, has sometimes 
seemed to me distinctly to intensify the pains. 

Precautions. — Bearing in mind the tendency of chloroform to pro- 
duce uterine relaxation, more than ordinary precautions should 
always be taken against post-partum hemorrhage in all cases in 
which it has been freely administered. 

In cases of operative midwifery it is often given to the extent of 
producing complete anaesthesia. In all such cases it should be admin- 
istered, when possible, by another medical man, and not by the 
operator, because the giving of chloroform to the surgical degree 
requires the undivided attention of the administrator, and no man 
can do this and operate at the same time, I once learnt an import 
ant lesson on this point. I had occasion to apply the forceps in the 
case of a lady who insisted on having chloroform. ' When commenc- 
ing the operation I noticed some suspicious appearances about the 
patient, who was a large stout woman, with a feeble circulation. I 
therefore stopped, allowed her to regain consciousness, and delivered 
her without anaesthesia, much to her own annoyance. Just one month 
after labor she went to a dentist to have a tooth extracted, and took 
chloroform, during the inhalation of which she died. This impressed 
on my mind the lesson that no man can do two things at the same 
time. The partial unconsciousness of incomplete anaesthesia, in 
which the patient is restless and tossing about, renders the applica- 
tion of forceps, as well as all other operations, very difficult. There- 
fore, unless the patient can be completely and fully anaesthetized, it 
is better to operate without chloroform being given at all. 

[In the United States chloroform is rarely used in obstetric practice, 
as compared with pure sulphuric ether, such as that prepared by Dr. 
Squibb, of New York ; and anaesthesia is much less frequently prac- 
tised than it was soon after its introduction. With some women, 
ether acts as a stimulant, increasing their power of expulsion, while 
at the same time the suffering is greatly lessened. The whole pro- 
cess of labor is perfect ; the placenta is extruded almost without 
blood, and there is no subsequent uterine relaxation. But unfortu- 
nately such cases are exceptional. With some patients the anaesthetic 
produces a species of intoxication, with hysterical excitement, and 
the pains, which are at first diminished, at last cease entirely, or are 
rendered of no value, and the ether has to be withheld, as we have 
frequently seen. Some women complain that they have a night- 



286 LABOR. 

mare, or are made to "feel wild," and are not relieved of pain, and 
request to have the anaesthetic withheld. But the chief cause for 
the infrequent resort to ether has been the production of uterine 
inertia after delivery, and consequent post-partum hemorrhage. In 
turning, the remedy is for the time important, but the delivery need 
not be completed under it. The use of fluid ext. ergot is a valuable 
prophylactic, but more to be relied upon in most instances where there 
has been no anaesthesia. — Ed.] 



CHAPTEE V. 

PELVIC PRESENTATIONS. 

Under the head of pelvic presentations it is customary to include 
all cases in which any part of the lower extremities of the child pre- 
sents. By some these are further subdivided into breech, footling, and 
Jcnee presentations ; but, although it is of consequence to be able to 
recognize the feet and the knee when they present, so far as the 
mechanism and management of delivery are concerned, the cases are 
identical, and, therefore, may be most conveniently considered to- 
gether. 

Frequency. — Presentations coming under this head are far from 
uncommon ; those in which the breech alone occupies the pelvis are 
met with, according to Churchill, once in 52 labors, while Kams- 
botham estimates that it presents more frequently, viz., once in 88.8 
labors. Footling presentations occur only once in 92 cases. They 
are probably often the mere conversion of original breech presenta- 
tions, the feet having come down during the labor, either in conse- 
quence of the sudden escape of the liquor amnii, when the breech 
was still freely movable above the brim, or from some other cause. 
Knee presentations are extremely rare, as may be readily understood 
if it be borne in mind that to admit them the thighs must be ex- 
tended, hence the vertical measurement of the child must be greatly 
increased, and therefore it could not be readily accommodated within 
the uterine cavity, unless of unusually small size. As a matter of 
fact, Mme. La Chapelle found only one knee presentation in upwards 
of 3000 cases. 

Causes. — The causes of pelvic presentations are not known. They 
are probably the same as those which produce other varieties of mal- 
presentations ; and it is not unlikely that, in certain women, there 
may be some peculiarity in the shape of the uterine cavity which 
favors their production. It would be difficult otherwise to explain 
such a case as that mentioned by Velpeau, in which the breech pre- 
sented in six labors. 



PELVIC PRESENTATIONS. 287 

Prognosis. — The results, as regards the mother, are in no way more 
unfavorable than in vertex presentation. The first stage of the labor 
is generally tedious, since the large rounded mass of the breech does 
not adapt itself so well as the head to the lower segment of the uterus, 
and dilatation of the cervix is consequently apt to be retarded. The 
second stage is, however, if anything, more rapid than in vertex 
cases ; and even when it is protracted, the soft breech does not pro- 
duce such injurious pressure on the maternal structures as the hard 
and unyielding head. 

The Infantile Mortality in Pelvic Presentations. — The result is very 
different as regards the child. Dubois calculated that 1 out of 11 
children was still-born. Churchill estimates the mortality as much, 
higher, viz., 1 in 3gth. The latter certainly indicates a larger num- 
ber of still- births than is consistent with the experience of most 
practitioners, and more than should occur if the cases be properly 
managed ; but there can be no doubt that the risk to the child is, 
even under the most favorable circumstances, very great. Even when 
the child is not lost it may be seriously injured. Dr. Kuge has tabu- 
lated a series of 29 cases in which there were found to be fractures of 
bones or other injuries. 1 

Causes of Foetal Mortality. — The chief source of danger is pressure 
on the umbilical cord, in the interval elapsing between the birth of 
the body and the head. At this time the cord is very generally com- 
pressed between the head of the child and the pelvic walls, so that 
circulation in its vessels is arrested. Hence the aeration of the foetal 
blood cannot take place ; and, pulmonary respiration not having been 
yet established, the child dies asphyxiated. There are other condi- 
tions present which tend, although in a minor degree, to produce the 
same result. One of these is that the placenta is probably often 
separated by the uterine contractions when the bulk of the body is 
being expelled, as, indeed, takes place, under analogous circum- 
stances, when the vertex presents ; the necessary result being the arrest 
of placental respiration. Joulin thinks that the same effect may be 
produced by the compression of the placenta between the contracted 
uterus and the hard mass of the foetal skull. Probably all these 
causes combine to arrest the functions of the placenta; and, if the 
delivery of the head, and consequently the establishment of pulmo- 
nary respiration, be delaj^ed, the death of the child is almost inevi- 
table. The corollary is that the danger to the child is in direct 
proportion to the length of time that elapses between the birth oi 
the body and that of the head. 

The risk to the child is greater in footling than in breech cases, 
because in the former the maternal structures are less perfectly di- 
lated, in consequence of the small size of the feet and thighs, and, 
therefore, the birth of the head is more apt to be delaj^ed. 

Diagnosis. — Inasmuch as the long axis of the child corresponds 
with the long axis of the uterus, in pelvic as in vertex presentations, 
there is nothing in the shape of the uterus to arouse suspicion as to 

1 Bui. G6n. de Therap., August, 1875. 



288 LABOR. 

the character of the case. Still, it is often sufficiently easy to recog- 
nize a pelvic presentation by abdominal examination, if we have 
occasion to make one. The facility with which it may be done de- 
pends a good deal on the individual patient. If she be not very 
stont, and if the abdominal parietes be lax and non-resistant, we 
shall generally be able to feel the round head at the upper part of 
the uterus much firmer, and more defined in outline than the breech. 
The conclusion will be fortified if we hear the foetal heart beating on 
a level with, or above, the umbilicus. The greater resistance on one 
side of the abdomen will also enable us to decide, with tolerable ac- 
curacy, to which side the back of the child is placed. Information 
thus acquired is, at the best, uncertain ; and we cau never be quite 
sure of the existence of a pelvic presentation until we can corrobo- 
rate the diagnosis by vaginal examination. 

Results of Vaginal Examination. — The first circumstance to ex- 
cite suspicion on examination per vaginam, even when the os is un- 
dilated, is the absence of the hard globular mass felt through the 
lower segment of the uterus, which is so characteristic of vertex 
presentations. When the os is sufficiently open to allow the mem- 
branes to protrude, although the presenting part is too high up to be 
within reach, we may be struck with the peculiar shape of the bag 
of membranes, which, instead of being rounded, projects a consider- 
able distance through the os, like the finger of a glove. This is a 
peculiarity met with in all malpresentations alike, and is, indeed, 
much less distinct in breech than in footling presentations, because 
in the former the membranes are more stretched, just as they are in 
vertex cases. When the membranes rupture, instead of the waters 
dribbling away by degrees, they often escape with a rush, in conse- 
quence of the pelvic extremity not filling up the lower part of the 
uterus so accurately as the head, which acts as a sort of ball-valve, 
and prevents the sudden and complete discharge of the waters. 

Diagnosis of the Breech. — Often, on first examining, even when the 
membranes are ruptured, the presentation is too high up to be made 
out accurately. All that we can be certain of is, that it is not the 
head ; and the case must be carefully watched, and examinations 
frequently repeated, until the precise nature of the presentation can 
be established. If the breech present, the finger first impinges on a 
round, soft prominence, on depressing which a bony protuberance, 
the trochanter major, can be felt. On passing the finger upwards it 
reaches a groove, beyond which a similar fleshy mass, the other 
buttock, can be felt. In this groove various characteristic points, 
diagnostic of the presentation, can be made out. Towards one end 
we can feel the movable tip of the coccyx, and above it the hard 
sacrum, with rough projecting prominences. These points, if accu- 
rately made out, are quite characteristic, and resemble nothing in 
any other presentation. In front there is the anus, in which it is 
sometimes, but by no means always, possible to insert the tip of the 
finger. If this can be done it is easy to distinguish it from the 
mouth, with which it might be confounded, by observing that the 
hard alveolar ridges are not contained Avithin it. Still more in front 



PELVIC PRESENTATIONS. 289 

we may find the genital organs, the scrotum in male children being 
often much swollen if the labor has been protracted. Thus it is often 
possible to recognize the sex of the child before birth. 

Differential Diagnosis. — The breech might be mistaken for the 
face, especially if the latter be much swollen ; but this mistake can 
readily be avoided by feeling the spinous processes of the sacrum. 

The knee is recognized by its having two tuberosities with a de- 
pression between them. It might be confounded with the heel, the 
elbow, or the shoulder. From the heel, it is distinguished by having 
two tuberosities instead of one ; from the elbow, by the latter having 
one sharp tuberosity, with a depression on each side, instead of a 
central depression and two lateral prominences ; and from the 
shoulder, by the latter being more rounded, having only one promi- 
nence, running from which the acromion and clavicle can be traced. 

Diagnosis of the Foot. — The foot may be mistaken for the hand. 
This error will be avoided by remembering that all the toes are in 
the same line, and that the great toe cannot be brought into apposi- 
tion with the others, as the thumb can with the fingers. The internal 
border of the foot is much thicker than the external, whereas the 
two borders of the hand are of the same thickness. Moreover, the 
foot is articular at right angles to the leg, and cannot be brought 
into a line with it, as the hand can with the arm. Finally, the pro- 
jection of the calcaneum is characteristic, and resembles nothing in 
the hand. 

Mechanism. — As is the case in other presentations, obstetricians 
have very variously subdivided breech presentations, with the effect 
of needlessly complicating the subject. The simplest division, and 
that which will most readily impress itself on the memory of the 
student, is to describe the breech as presenting in four positions, 
analogous to those of the vertex, the sacrum being taken as repre- 
senting the occiput, and the positions being numbered according to 
the part of the pelvis to which it points. Thus we have — 

First, or left s aero -anterior (corresponding to the first position ot 
the vertex). The sacrum of the child points to the left foramen 
ovale of the mother. 

Second, or right s aero -anterior (corresponding to the second vertex 
position). The sacrum of the child points to the right foramen ovale 
of the mother. 

Third, or right sacroposterior (corresponding to the third vertex 
position). The sacrum of the child points to the right sacro-iliac 
synchondrosis of the mother. 

Fourth, or left sacroposterior (corresponding to the fourth vertex 
position). The sacrum of the child points to the left sacro-iliac 
synchondrosis of the mother. 

Of these, as with the corresponding vertex positions, the first and 
third are the most common, their comparative frequency, no doubt, 
depending on the same causes. The mechanical conditions to which 
the presenting part is subjected are also identical, but the alterations 
of positions of the breech in its progress are by no means so uniform 
as those of the head, on account of its less perfect adaptation to the 



290 



LABOR. 



pelvic cavity. The mechanism of the delivery of the shoulders and 
head in breech presentations, moreover, is of much greater practical 
importance than that of the body in vertex presentations, inasmuch 
as the safety of the child depends on its speedy and satisfactory ac- 
complishment. Bearing these facts in mind, it will suffice to describe 
briefly the phenomena of delivery in the first and third breech 
positions. 

Fig. 104. 




First or left Sacro-cotyloid Position of the Breech. 



Position of the Child at Brim. — -In the first position the sacrum of 
the child points to the left foramen ovale , its back is consequently 
placed to the left side of the uterus and anteriorily, and its abdomen 
looks to the right side of the uterus and posteriorly. The sulcus 
between the buttocks lies in the right oblique diameter of the pelvis, 
while the transverse diameter of the buttocks lies in the left oblique 
diameter, the left buttock being most easily within reach. As in 
vertex presentations the hips of the child lie on the same level at 
the pelvic brim, although ISTaegele describes the left hip as placed 
lower than the right. 

Descent. — As the pains act on the bod}^ of the child, the breech 
is gradually forced through the pelvic cavity, retaining the same 
relations as at the brim, its progress being generally more slow than 
that of the head, until it reaches the lower pelvic strait, when the 
same mechanism which produces rotation of the occiput comes to 
operate upon it. The result is a rotation of the child's pelvis, so 
that its transverse diameter comes to lie approximately in the antero- 
posterior diameter of the outlet, its antero-posterior diameter corre- 
sponds to the transverse diameter of the mother's pelvis, the left hip 
lies behind the pubis, and the right towards the sacrum. This rota- 



PELVIC PRESENTATIONS. 



291 



tion, which is admitted by the majority of obstetricians, is altogether 
denied by Naegele. There can be no donbt, however, that it does 
generally take place, but by no means so constantly as the corre- 
sponding rotation of the vertix ; and it is not uncommon for it to 
be entirely absent, and for the hips to be born in the oblique diam- 
eter of the outlet. The body of the child is said frequently not 
to follow the movement imparted to the hips, so that there is more 
or less of a twist in the vertebral column. 

Expulsion of the Hips and Body. — The left hip now becomes firmly 
fixed behind the pubis, and a movement of extension, analogous to 
that of the head in vertex presentations, takes place. The right, or 
posterior, hip revolves round the fixed one, gradually distends the 
perineum, and is expelled first, the left hip rapidly following. As 
soon as both hips are born, the feet slip out, unless the legs are com- 
pletely extended upon the child's abdomen. The shoulders soon 
follow, lying in the left oblique diameter of the pelvis. The left 
shoulder rotates forwards behind the pubis, where it becomes fixed, 
the right shoulder sweeping over the perineum, and being born 
first. The arms of the child are generally found placed upon its 
thorax, and are born before the shoulders. Sometimes they are ex- 
tended over the child's head, thus causing considerable delay, and 
greatly increasing the risk to the child. It is now generally ad- 
mitted that such extension is most apt to occur when traction has 
been made on the child's body with the view of hastening delivery, 
and that it is rarely met with when the expulsion of the body is left 
entirely to the natural powers. 

Delivery of the Head. — When the shoulders are expelled the head 
enters the pelvis in the opposite, or right oblique diameter, the face 
looking to the right sacro-iliac synchondrosis. As the greater part 



Fig. 105. 




Passage of the Shoulders and Partial Rotation of the Thorax. 



of the child is now expelled, and as the head has entered the vagina, 
the uterus, having a comparatively small mass to contract upon, 
must obviously act at a mechanical disadvantage. Still the pressure 
of the head on the vagina is a powerful inciter, the accessory muscles 



292 LABOR. 

of parturition are brought into strong action, and there is usually 
quite sufficient force to insure expulsion of the head without artificial 
aid. On account of the great resistance to the descent of the occiput 
from its articulation with the spinal column, the pains have the 

Fig. 106.. 




Desceut of the Head. 

effect of forcing down the anterior portion of the head, and this 
insures the complete flexion of the chin upon the sternum. This is 
a great advantage from a mechanical point of view, as it causes the 
short occipito mental diameter of the head to enter the pelvis in the 
axis of the uterus and the brim. If the head should be in a state 
of partial extension — as sometimes happens when the pelvis is un- 
usually roomy — the occipital frontal diameter is placed in a similar 
relation to the brim, a position certainly less favorable to the easy 
birth of the head. As the head descends it experiences a movement 
of rotation, the occiput passing forwards and to the right, behind the 
pubic arch, the face turning backwards into the hollow of the sacrum. 
The body of the child will be observed to follow this movement, so 
that its back is turned towards the mother's abdomen, its anterior 
surface to the perineum. The nape of the neck now becomes firmly 
fixed under the arch of the pubis, the pains act chiefly on the ante- 
rior portion of the head, and cause it to sweep over the perineum, 
the chin being first born, then the mouth and forehead, and lastly 
the occiput. 

Sacro-posterior Positions. — It is needless to describe the differences 
between the mechanism of the second and first positions, which the 
student, who has mastered the subject of vertex presentations, will 
readily understand. It is necessary, however, to say a few words as 
to sacro-posterior positions, choosing for that purpose the third, which 
is the more common of the two. This is exactly the opposite of the 
first position. The sacrum of the child points to the right sacro- 
iliac synchondrosis, its abdomen looks forward and to the left side 
of the mother. The transverse diameter of the child's pelvis lies in 
the left oblique diameter, the right hip being anterior. The birth of 



PELVIC PRESENTATIONS. 293 

the body generally takes place exactly in the way that has been 
already described, the right hip being towards the pubis. 

As the head descends into the pelvis the occiput most usually 
rotates along its right side — the rotation having been often already 
partially effected when that of the hips had been made — until it comes 
to rest behind the pubis, the face passing backwards along the left 
side of the pelvis into the hollow of the sacrum. This change cor- 
I responds exactly to the anterior rotation of the occiput in occipito- 
posterior positions, and is the natural and favorable termination. 

Sometimes, forward rotation does not take place, and the occiput 
then turns backwards into the hollow of the sacrum. What then 
generally occurs is that the pains continue, for the reason already 
mentioned, to depress the chin and produce strong flexion of the face 
on the sternum, the occiput becoming fixed on the anterior border 
of the perineum. The pains continuing to act chiefly on the anterior 
part of the head, the face is born first behind the pubis, the occiput 
only slipping over the perineum after the forehead has been ex- 
! pelled. 

Second Mode in which such Cases occasionally Unci. — A second mode 
of termination of such positions is mentioned in most works, on the 
I authority of one or two recorded cases ; but although mechanically 
possible, it is certainly an event of extreme rarity. The chin, in- 
stead of being flexed on the sternum, is greatly extended, so that 
the face of the child looks upwards towards the pelvic brim. The 
chin then hitches over the upper edge of the pubis and becomes fixed 
there, while the force of the uterine contractions is expended on the 
posterior part of the head, which descends through the pelvis, dis- 
tending the perineum, and is born first, the face subsequently fol- 
lowing. 

Mechanism of Feet Presentation. — The mechanism of the delivery 
of the body and head in cases in which the feet originally present, 
does not differ, in any important respect, from that which has been 
already described, and requires no separate notice. 
, Treatment. — From what has been said of the natural mechanism, 
it is evident that one of the most fruitful causes of difficulty and 
complication is undue interference on the part of the practitioner. 
It is, no doubt, tempting to use traction on the partially born trunk 
in the hope of expediting delivery ; but when it is remembered that 
this is almost certain to produce extension of the arms above the 
head, and subsequently extension of the occiput on the spine, both 
of which seriously increase the difficulty of delivery, the necessity 
of leaving the case as much as possible to nature will be apparent. 

Having once, therefore, determined the existence of a pelvic pre- 
sentation, nothing more should be done until the birth of the breech. 
The membranes should be even more carefully prevented from pre- 
maturely rupturing than in vertex presentations, since they serve to 
dilate the genital passages better than the presenting part. Hence 
they should be preserved intact, if possible, until they reach the floor 
of the pelvic, instead of being punctured as soon as the os is fully 



291 LABOR. 

dilated. The breech when born should be received and supported 
in the palm of the hand. 

Danger to Child. — -"When the body is expelled as far as the umbili- 
cus, the dangers to the chiid commence ; for now the cord is apt to 
be pressed between the body of the child and the pelvic walls. To 
obviate this risk as much as possible, a loop of the cord should be 
pulled down, and carried to that part of the pelvis where there is 
most room, which will generally be opposite one or the other sacro- 
iliac synchondrosis. As long as the cord is freely pulsating we may 
be satisfied that the life of the child is not gravely imperilled, al- 
though delay is fraught with danger, from other sources which have 
been already indicated. In most cases the arms now slip out ; but 
it may happen, even without any fault on the part of the accouche nr, 
that they are extended above the head, and it is of great importance 
that we should be thoroughly acquainted with the best means of 
liberating them from their abnormal position. 

Management when the Arms are extended above the Head. — They 
must, of course, never be drawn directly downwards, or the almost 
certain result would be fracture of the fragile bones. We should 
endeavor to make the arm sweep over the face and chest of the child, 
so that the natural movements of its joints should not be opposed. 
If the shoulders be within easy reach, the finger of the accoucheur 
should be slipped over that which is posterior — because there is 
likely to be more space for this manoeuvre towards the sacrum — 
and gently carried downwards towards the elbow, which is drawn 
over the face, and then onwards, so as to liberate the forearm. The 
same manoeuvre should then be applied to the opposite arm. It may 
be that the shoulders are not easily reached, and then they may be 
depressed by altering the position of the child's body. If this be 
carried well up to the mother's abdomen, the posterior shoulder will 
be brought lower down ; and, by reversing this procedure and carry- 
ing the body back over the perineum, the anterior shoulder may be 
similarly depressed. It is only very exceptionally, however, that 
these expedients are required. 

Birth of the Head. — The arms being extracted, some degree of ar- 
tificial assistance is, at this time, almost always required. If there 
be much delay, the child will almost certainly perish. Attempts 
have been made, in cases in which delivery of the head could not 
be rapidly effected, to established pulmonary respiration by passing 
one or two fingers into the vagina, so as to press it back and admit 
air to the child's mouth, or by passing a catheter or tube into the 
mouth. Neither of these expedients are reliable, and we should 
rather seek to aid nature in completing the birth of the head as rap- 
idly as possible. The first thing to do, supposing the face to have 
rotated into the cavity of the sacrum, is to carry the body of the 
child well up towards the pubis and abdomen of the mother without 
applying any traction, for fear of interfering with the all-important 
flexion of. the chin on the sternum. If now the patient bear down 
strongly, the natural powers may be sufficient to complete delivery. 
If there be any delay, traction must be resorted to, and we must en- 



PELVIC PRESENTATIONS. 295 

cleavor to apply it in such a way as to insure flexion. For this pur- 
pose, while the body of the child is grasped by the left hand, and 
drawn upwards towards the mother's abdomen, the index and middle 
fingers of the right hand are placed on the back of the child's neck, 
so that their tips press on either side of the base of the occiput, and 
push the head into a state of 'flexion. In most works we are advised 
to pass the index and middle fingers of the left hand at the same 
time over the child's face, so as to depress the superior maxilla. Dr. 
Barnes insists that this is quite unnecessary, and that extraction in 
the manner indicated, by pressure on the occiput, is quite sufficient. 
Should it not prove so, flexion of the chin may be very effectually 
assisted by downward pressure on the forehead through the rectum. 
One or two fingers of the left hand can readily be inserted into the 
bowel, and the expulsion of the head is thus materially facilitated. 

Value of Pressure through the Abdomen. — By far the most power- 
ful aid, however, in hastening delivery of the head, should delay 
occur, is pressure from above. This has been, strangely enough, 
almost altogether omitted by writers on the subject. It has been 
strongly recommended by Professor Penrose, and there can be no 
question of its utility. Indeed, as the uterus contracts tightly round 
the head, uterine expression can be applied almost directly to the 
head itself, and without any fear of deranging its proper relation to 
the maternal passages. It is very seldom, indeed, that a judicious 
combination of traction on the part of the accoucheur, with firm 
pressure through the abdomen applied by an assistant, will fail in 
effecting delivery of the head before the delay has had time to prove 
injurious to the child. 

Application of the Forceps to the After -coming Head. — Many accou- 
cheurs — 'among others Meigs, and Rigby — advocate the application 
of the forceps when there is delay in the birth of the after-coming 
head. If the delay be due to want of expulsive force in a pelvis of 
normal size, manual extraction, in the manner just described, will be 
found to be sufficient in almost every case, and preferable, as being 
more rapid, easier of execution, and safer to the child. The forceps 
may be quite properly tried, if other means have failed ; especially 
if there be some disproportion between the size of the head and the 
pelvis. 

Management of Sacro-posterior Positions. — Difficulties in delivery 
may also occur in sacro-posterior positions. Up to the time of the 
birth of the head the labor usually progresses as readily as in sacro- 
anterior positions. If the forward rotation of the hips do not take 
place, much subsequent difficulty may be prevented by gently favor- 
ing it by traction applied to the breech during the pains, the finger 
being passed for this purpose into the fold of the groin. 

It is after the birth of the shoulders that the absence of rotation is 
most likely to prove troublesome. It has been recommended that 
the body should then be grasped, in the interval between the pains, 
and twisted round so as to bring the occiput forward. It is by no 
means certain, however, that the head would follow the movement 
imparted to the body, and there must be a serious danger of giving 



296 LABOR. 

a fatal twist of the neck by such a manoeuvre. The better plan is to 
direct the face backwards, towards the cavity of the sacrum, by 
pressing on the anterior temple during the continuance of a pain. 
In this way the proper rotation will generally be effected without 
much difficulty, and the case will terminate in the usual way. 

Management of Cases in which Forward Rotation does not occur. — If 
rotation of the occiput forwards do not occur, it is necessary for the 
practitioner to bear in mind the natural mechanism of delivery under 
such circumstances. In the majority of cases the proper plan is to 
favor flexion of the chin by upward pressure on the occiput, and to 
exert traction directly backwards, remembering that the nape of the 
neck should be fixed against the anterior margin of the perineum. 
If this be not remembered, and traction be made in the axis of the 
pelvic outlet, the delivery of the head will be seriously impeded. In 
the rare cases in which the head becomes extended, and the chin 
hitches on the upper margin of the pubis, traction directly forwards 
and upwards may be required to deliver the head ; but before resort- 
ing to it care should be taken to ascertain that backward extension 
of the head has really taken place. 

Management of Impacted Breech Presentations. — It remains for us 
to consider the measures which may be adopted in those very 
troublesome cases in which the breech refuses to descend, and be- 
comes impacted in the pelvic cavity, either from uterine inertia, or 
from disproportion between the breech and the pelvis. Here, un- 
fortunately, the peculiar shape of the presenting part, which is un- 
adapted for the application of the forceps, renders such cases very 
difficult to manage. 

Two measures have been chiefly employed : 1st, bringing down 
one or both feet, so as to break up the presenting part, and convert 
it into a footling case ; 2d, traction on the breech, either by the 
fingers, a blunt hook, or fillet passed over the groin. 

Barnes insists on the superiority of the former plan, and there can 
be no question that, if a foot can be got down, the accoucheur has a 
complete control over the progress of the labor, which he can gain 
in no other way. If the breech be arrested at or near the brim, there 
will generally be no great difficulty in effecting the desired object. 
It will be necessary to give chloroform to the extent of complete 
anaesthesia, and to pass the hand over the child's abdomen in the 
same manner, and with the same precautions, as in performing podalic 
version, until a foot is reached, which is seized and pulled down. If 
the feet be placed in the usual way close to the buttocks, no great 
difficulty is likely to be experienced. If, however, the legs be ex- 
tended on the abdomen, it will be necessary to introduce the hand 
and arm very deeply, even up to the fundus of the uterus, a proced- 
ure which is always difficult, and which may be very hazardous. 
Nor do I think that the attempt to bring down the feet can be safe 
when the breech is low down and fixed in the pelvic cavity. A 
certain amount of repression of the breech is possible, but it is 
evident that this cannot be safely attempted when the breech is at 
all low down. 



PRESENTATIONS OF THE FACE. 297 

Traction on the Groin. — Under such circumstances traction is our 
onlj resource, and this is always difficult and often unsatisfactory. 
Of all contrivances for this purpose none is better than the hand of 
the accoucheur. The index finger can generally be slipped over the 
groin without difficulty, and traction can be applied during the 
pains. Failing this, or when it proves insufficient, an attempt should 
be made to pass a fillet over the groins. A soft silk handkerchief, 
or a skein of worsted, answers best, but it is by no means easy to 
apply. The simplest plan, and one which is far better than the ex- 
pensive instruments contrived for the purpose, is to take a stout 
piece of copper wire and bend it double into the form of a hook. 
The extremity of this can generally be guided over the hips, and 
through its looped end the fillet is passed. The wire is now with- 
drawn, and carries the fillet over the groins. I have found this 
simple contrivance, which can be manufactured in a few moments, 
very useful, and by means of such a fillet ver}^ considerable tractive 
force can be employed. The use of a soft fillet is in every way pre- 
ferable to the blunt hook which is contained in most obstetric bags. 
A hard instrument of this kind is quite as difficult to apply, and any 
strong traction employed by it is almost certain to seriously injure 
the delicate foetal structures over which it is placed. As an auxiliary 
the employment of uterine expression should not be forgotten, since 
it may give material aid when the difficulty is only due to uterine 
inertia. 

Embryotomy. — Failing all endeavors to deliver by these expedients, 
there is no resource left but to break up the presenting part by scis- 
sors, or by craniotomy instruments ; but fortunately so extreme a 
measure is but rarely necessary. 



CHAPTEK VI. 

PRESENTATIONS OF THE FACE. 

Presentations of the face are by no means rare ; and, although 
in the great majority of cases they terminate satisfactorily by the 
unassisted powers of nature, yet every now and again they give rise 
to much difficulty, and then they may be justly said to be amongst 
the most formidable of obstetric complications. It is, therefore, 
essential that the practitioner should thoroughly understand the 
natural history of this variety of presentation, with the view of 
enabling him to intervene with the best prospect of success. 

Erroneous Views formerly held on the Subject. — -The older accou- 
cheurs held very erroneous views as to the mechanism and treatment 
20 



298 LABOR. 

of these cases, most of them believing that delivery was impossible 
by the natural efforts, and that it was necessary to intervene by 
version in order to effect delivery. Smellie recognized the fact that 
spontaneous delivery is possible, and that the chin turns forwards 
and under the pubis; but it was not until long after his time, and 
chiefly after the appearance of Mme. La Chapelle's essay on the 
subject, that the fact that most cases could be naturally delivered 
was fully admitted and acted upon. 

Frequency. — The frequency of face presentations varies curiously in 
different countries. Thus, Collins found that in the Eotunda Hos- 
pital there was only 1 case in 497 labors, although Churchill gives 
1 in 249 as the average frequency in British practice ; while in Ger- 
many this presentation is met with once in 169 labors. The only 
reasonable explanation of this remarkable difference is, that the 
dorsal decubitus, generally followed abroad, favors the transforma- 
tion of vertex presentations into those of the face. 

The mode in which this change is effected — for it can hardly be 
doubted that, in the large majority of cases, face presentation is due 
to a backward displacement of the occiput after labor has actually 
commenced, but before the head has engaged in the brim — has been 
made the subject of various explanations. 

Mode in which Face Presentations are produced. — It has generallv 
been supposed that the change is induced by a hitching of the 
occiput on the brim of the pelvis, so as to produce extension of 
the head, and descent of the face ; the occurrence being favored by 
the oblique position of the uterus so frequently met with in preg- 
nancy. Hecker attaches considerable importance to a peculiarity 
in the shape of the foetal head generally observed in face pre- 
sentations, the cranium having the dolicho-cephalous form, promi- 
nent posteriorly, with the occiput projecting, which has the effect of 
increasing the length of the posterior cranial lever arm, and facili- 
tating extension when circumstances favoring it are in action. Dr. 
Duncan 1 thinks that uterine obliquity has much influence in the 
production of face presentation, but in a different way from that 
above referred to. He points out that, when obliquity is verv 
marked, a curve in the genital passages is produced, the convexitv 
of which is directed to the side towards which the uterus is deflected. 
When uterine contraction commences, the foetus is propelled down- 
wards, and the concavity of the curve is acted on to the greatest ad- 
vantage by the propelling force, and tends to descend. Should the 
occiput happen to lie in the convexity of the curve so formed, the 
tendency will be for the forehead to descend. In the majority of 
cases its descent will be prevented by the increased resistance it 
meets with, in consequence of the greater length of the anterior cra- 
nial lever arm ; but if the uterine obliquity be extreme, this may 
be counterbalanced, and a face presentation ensues. The influence 
of this obliquity is corroborated by the observation of Baudelocque, 
that the occiput in face presentations almost invariably corresponds 
to the side of the uterine obliquity. A further corroboration is 

1 Edin. Med. Jour., vol. xv. 



PRESENTATIONS OF THE FACE. 299 

afforded by the fact, that in face presentation the occiput is much 
more frequently directed to the right than to the" left; while right 
lateral obliquity of the uterus is also much more common. 

These theories assume that face presentations are produced during 
labor. In a few cases they certainly exist before labor has com- 
menced. It is possible, however, as we know that uterine contrac- 
tions exist independently of actual labor, that similar causes may 
also be in operation, although less distinctly, before the commence- 
ment of labor. 

Diagnosis. — The diagnosis is often a matter of considerable diffi- 
culty at an early period of labor, before the os is fully dilated and 
the membranes ruptured, and when the face has not entered the 
pelvic cavity. The finger then impinges on the rounded mass of the 
forehead, which may very readily be mistaken for the vertex. At 
this stage the diagnosis may be facilitated by abdominal palpation 
in the way suggested by Hecker. If the face is presenting at the 
brim, palpation will enable us to distinguish a hard, firm, and 
rounded body, immediately above the pubis, which is the forehead 
and sinciput ; on the other side will be felt an indistinct soft sub- 
stance, corresponding to the thorax and neck. When labor is ad- 
vanced, and the head has somewhat descended, or when the 
membranes are ruptured, we should be able to make out the nature 
of the presentation with certainty. The diagnostic marks to be 
relied on are the edges of the orbits, the prominence of the nose, the 
nostrils (their orifices showing to which part of the pelvis the chin 
is turned), and the cavity of the mouth, with the alveolar ridges. 
If these be made out satisfactorily, no mistake should occur. The 
most difficult cases are those in which the face has been a consider- 
able time in the pelvis. Under such circumstances the cheeks be- 
come greatly swollen and pressed together, so as to resemble the 
nates. The nose might then be mistaken for the genital organs, and 
the mouth for the anus. The orbits, however, and the alveolar 
ridges, resemble nothing in the breech, and should be sufficient to 
prevent error. Considerable care should be taken not to examine 
too frequently and roughly, otherwise serious injury to the delicate 
structures of the face might be inflicted. When once the presenta- 
tion has been satisfactorily diagnosed, examinations should be made 
as seldom as possible, and only to assure ourselves that the case is 
progressing satisfactorily. 

Mechcmism. — If we regard face presentations, as we are fully justi- 
fied in doing, as being generally produced by the extension of the 
occiput in what were originally vertex presentations, we can readily 
understand that the position of the face in relation to the pelvis must 
correspond to that of the vertex. This is, in fact, what is found to 
be the case, the forehead occupying the position in which the occiput 
would have been placed had extension not occurred. 

The Positions of the Face correspond to those of the Vertex. — The 
face, then, like the head, may be placed with its long diameter 
corresponding to almost any of the diameters of the brim, but most 
generally it lies either in the transverse diameter, or between this 



800 LABOR. 

and the oblique, while, as it descends in the pelvis, it more generally 
occupies one or other of the oblique diameters. It is common in 
obstetric works to describe two principal varieties of face presenta- 
tion, viz., the right and left mento-iliac, according as the chin is 
turned to one or other side of the pelvis. It is better, however, to 
classify the positions in accordance with the part of the pelvis to 
which the chin points. We may, therefore, describe four positions 
of the face, each being analogous to one of the ordinary vertex 
presentations, of which it is the transformation. 

First position. — The chin points to the right sacro-iliac synchon- 
drosis, the forehead to the left foramen ovale, and the long diameter 
of the face lies in the right oblique diameter of the pelvis. This 
corresponds to the first position of the vertex, and, as in that, the 
back of the child lies to the left side of the mother. 

Second position. — The chin points to the left sacro-iliac synchon- 
drosis, the forehead to the right foramen ovale, and the long diameter 
of the face lies in the left oblique diameter of the pelvis. This is 
the conversion of the second vertex position. 

Fig. 107. 




Second Position in Face Presentations. 

Third position. — The forehead points to the right sacro-iliac syn- 
chondrosis, the chin to the left foramen ovale, and the long diameter 
of the face lies in the right oblique diameter of the pelvis. This is 
the conversion of the third vertex position. 

Fourth position. — The forehead points to the left sacro-iliac syn- 
chondrosis, the chin to the right foramen ovale, and the long dia- 
meter of the face lies in the left oblique diameter of the pelvis. This 
is the conversion of the fourth vertex position. 



PRESENTATIONS OF THE FACE. 301 

Relative Frequency of these Positions. — The relative frequency of 
these presentations is not yet positively ascertained. It is certain 
that there is not the preponderance of first facial that there is of first 
vertex positions, and this may, no doubt, be explained by the suppo- 
sition that an unusual vertex position may of itself facilitate the 
transformation into a face presentation. Winckel concludes that, 
cseteris paribus, a face presentation is more readily produced when 
the back of the child lies to the right than when it lies to the left 
side of the mother; the reason for this being probably the frequency 
of right lateral obliquity of the uterus. We shall presently see that, 
with very rare exceptions, it is absolutely essential that 'the chin 
should rotate forwards under the pubis before delivery can be 
accomplished; and, therefore, we may regard the third and fourth 
face positions, in which the chin from the first points anteriorly, as 
more favorable than the first and second. 

Mechanism. — The mechanism of delivery in face is practically the 
same as in vertex presentations ; and we shall have no difficulty in 
understanding it if we bear in mind that in face cases the forehead 
takes the place, and represents, the occiput in vertex presentations. 
For the purpose of description we will take the first position of the 
face — 

Description of Delivery in the First Position of the Face. — 1. The 
first step consists in the extension of the head, which is effected by 
the uterine contractions as soon as the membranes are ruptured. Bv 
this the occiput is still more completely pressed back on the nape of 
the neck, and the fronto- mental, rather than the mento-bregmatic, 
diameter is placed in relation to the pelvic brim. This corresponds 
to the stage of flexion in vertex presentations. 

The chin descends below the forehead, from precisely the same 
cause as the occiput in vertex presentations. On account of the ex- 
tended position of the head the presenting face is divided into por- 
tions of unequal length in relation to the vertebral column, through 
which the force is applied, the longer lever arm being towards the 
forehead. The resistance is, therefore, greatest towards the fore- 
head, which remains behind while the chin descends. 

2. Descent. — -As the pains continue, the head (the chin being still 
in advance) is propelled through the pelvis. It is generally said that 
the. face cannot descend, like the occiput, down to the floor of the 
pelvis, its descent being limited by the length of the neck. There is 
here, however, an obvious misapprehension. The neck, from the 
chin to the sternum, when the head is forcibly extended, measures 
from 3 J to 4 inches, a length that is more than sufficient to admit of 
the face descending to the lower pelvic strait. As a matter of fact 
the chin is frequently observed in mento-posterior positions to de- 
scend so far that it is apparently endeavoring to pass the perineum 
before rotation occurs. At the brim the two sides of the face are on 
a level, but, as labor advances, the right cheek descends somewhat, 
the caput succedaneum forms on the malar bone, and, if a secondary 
caput succedaneum form, on the cheek. 

3. Rotation is by far the most important point in the mechanism 



302 



LABOR. 



of face presentations ; for unless it occurs, delivery, with a full-sized 
head and an average pelvis, is practically impossible. There are, no 



Fig. 108. 




notation Forwards of Chin. 



doubt, exceptions to this rule, which must be separately considered, 
but it is certain that the absence of rotation is always a grave and 



Fig. 109. 




Passage of the Head through the External Parts in Face Presentation. 

formidable complication of face presentation. Fortunately it is only 
very rarely that it is not effected. The mechanical causes are pre- 



PRESENTATIONS OF THE FACE. 



303 



cisel y those which produce rotation of the occiput forwards in vertex 
presentations. As it is accomplished, the chin passes under the arch 
of the pubis, and the occiput rotates into the hollow of the sacrum 
(Fig. 108) ; and then commences — 

4. Flexion, a movement which corresponds to extension in vertex 
cases. The chin passes as far as it can under the pubic arch, and 
there becomes fixed. The uterine force is now expended on the oc- 
cupit, which revolves, as it were, on its transverse axis (Fig 109), 
the under surface of the chin resting on the pubis as a fixed point. 
This movement goes on until, at last, the face and occiput sweep over 
the distended perineum. 

5. External Rotation is precisely similar to that which takes- place 
in head presentations, and, like it, depends on the movements im- 
parted to the shoulders. 

Fig. 110. 




Illustrating the Position of the Head when Forward Rotation of the Chin 
does not take place. 



Such is the natural course of delivery in the vast majority of 
cases ; but, in order fully to understand the subject, it is necessary 
to study those rare cases in which the chin points backwards, and 
forward rotation does not occur. These may be taken to correspond 
to the occipito-posterior positions, in which the face is born looking 
to the pubes ; but, unlike them, it is only very exceptional^ that 
delivery can be naturally completed. The reason of this is obvious, 
for the occiput gets jammed behind the pubis, and there is no space 
for the fronto-mental diameter to pass the antero-posterior diameter 
of the outlet (Fig. 110). Cases are indeed recorded, in which delivery 
has been effected with the chin looking posteriorly ; but there is 
every reason to believe that this can only happen when the head is 
either unusually small, or the pelvis unusually large. In such cases 
the forehead is pressed down until a portion appears at the ostium 



304 LABOR. 

vaginse, when it becomes firmly fixed behind the pubis, and the chin, 
after many efforts, slips over the perineum. When this is effected 
flexion occurs, and the occiput is expelled without difficulty. The 
forehead is probably always on a lower level than the chin. 

Dr. Hicks 1 has published a paper, in which he attempts to show 
that this termination of face presentations is not so rare as is gene- 
rally supposed, and he gives a single instance in which he effected 
delivery with the forceps; but he practically admits that special 
conditions are necessary, such as the " antero-posterior diameter of 
the outlet particularly ample," and a diminished size of the head. 
When delivery is effected it is probable, as Cazeaux has pointed out, 
that the face lies in the oblique diameter of the outlet, and that the 
chin depresses the soft structures at the side of the sacro-ischiatic 
notch, which yield to the extent of a quarter of an inch or more, 
and thereby permit the passage of the occipito-mental diameter of 
the head. It must, however, be borne well in mind, that spontaneous 
delivery in mento-posterior positions is the rare exception, and that, 
supposing rotation does not occur — and it often does so at the last 
moment — artificial aid in one form or another will be almost certainly 
required. 

Prognosis of Face Presentations. — As regards the mother, in the 
great majority of cases the prognosis is favorable, but the labor is 
apt to be prolonged, and she is, therefore, more exposed to the risks 
attending tedious delivery. As regards the child, the prognosis is 
much more unfavorable than in vertex presentations. Even when 
the anterior rotation of the chin takes place in the natural way, it is 
estimated that 1 out of 10 children is stillborn; while if not, the 
death of the child is almost certain. This increased infantile mor- 
tality is evidently due to the serious amount of pressure to which 
the child is subjected, and probably depends in many cases on cere- 
bral congestion, produced by pressure on the jugular veins, as the 
neck lies in the pelvic cavity. Even when the child is born alive, 
the face is always greatly swollen and disfigured. In some cases the 
deformity produced in this way is excessive, and the features are 
often scarcely recognizable. This disfiguration passes away in a few 
days; but the practitioner should be aware of the probability of its 
occurrence, and should warn the friends, or they might be unneces- 
■ sarily alarmed, and possibly might lay the blame on him. 

Treatment — After what has been said as to the mechanism of de* 
livery in face presentation, it is obvious that the proper course is to 
leave the case alone, in the expectation of the natural efforts being 
sufficient to complete delivery. Fortunately, in the large majority 
of cases, this course is attended by a successful result. 

The older accoucheurs, as has been stated, thought active inter- 
ference absolutely essential, and recommended either podalic version, 
or the attempt to convert the case into a vertex presentation, by in- 
serting the hand and bringing down the occiput. The latter plan 
was recommended by Baudclocque, and is even yet followed by some 

1 Obst. Trans., vol. vii. 



PRESENTATIONS OF THE FACE. 305 

accoucheurs. Thus Dr. Hoclge 1 advises it in all cases in which face 
presentation is detected at the brim ; but although it might not have 
been attended with evil consequences in his experienced hands, it is 
certainly altogether unnecessary^, and would infallibly lead to most 
serious results if generally adopted. It may, however, be allowable 
in certain cases in which the face remains above the brim, and re- 
fuses to descend into the pelvic cavity. Even then it is questionable 
whether podalic version should not be preferred, as being easier of 
performance, giving, when once effected, a much more complete 
control over delivery, and being less painful to the mother. Ver- 
sion is certainly preferable to the application of the forceps, which 
are introduced with difficulty in so high a position of the face, and 
do not take a secure hold. 

When once the face has descended into the pelvis, difficulties may 
arise from two chief causes ; uterine inertia, and non-rotation for- 
wards of the chin. 

The treatment of the former class must be based on precisely the 
same general principles as in dealing with protracted labor in vertex 
presentations. The forceps may be applied with advantage, bearing 
in mind the necessity of getting the chin under the pubis, and, when 
this has been effected, of directing the traction forwards, so as to 
make the occupit sloAvly and gradually distend and sweep over the 
perineum. 

Difficulties arising from Non-rotation of Chin Fomuards. — The 
second class of difficult face cases are much more important, and may 
try the resources of the accoucheur to the utmost. Our first en- 
deavor must be, if possible, to secure the anterior rotation of the chin. 
For this purpose various manoeuvres are recommended. By some, 
we are advised to introduce the finger cautiously into the mouth of 
the child, and draw the chin forwards during a pain ; by others, to 
pass the finger up behind the occiput and press it backwards during 
the pain. Schroeder points out that the difficulty often depends on 
the fact of the head not being sufficiently extended, so that the chin 
is not on a lower level than the forehead ; and that rotation is best 
promoted by pressing the forehead upwards with the finger during 
a pain, so as to cause the chin to descend. Penrose 2 believes that 
non-rotation is generally caused by the want of a point ofappui 
below, on account of the face being able to descend to the floor of 
the pelvis, and that, if this is supplied, rotation will take place. 
In such cases he applies the hand, or the blade of the forceps, so 
as to press on the posterior cheek. By this means the necessary 
" point d'appui " is given ; and he relates several interesting cases in 
which this simple manoeuvre was effectual in rapidly terminating 
a previously lengthy labor. Any, or all, of these plans may be 
tried. We must bear in mind, in using them, that rotation is often 
delayed until the face is quite at the lower pelvic strait, so that we 
need not too soon despair of its occurring. If, however, in spite 

1 System of Obstetrics, p. 335. 

2 Amer. Supplement to Obst Journ., April, 1876, 



306 LABOR. 

of these manoeuvres, it do not take place, what is to be done ? 
If, the head be not too low down in the pelvis to admit of version, 
that would be the simplest and most effectual plan. I have suc- 
ceeded in delivering in this way, when all attempts at producing 
rotation had failed; but generally the face will be too decidedly 
engaged to render it possible. An attempt might be made to bring 
down the occiput by the vectis, or by a fillet ; but, if the face be 
in the pelvic cavity, it is hardly possible for this plan to succeed. 
An endeavor may be made to produce rotation by the forceps ; 
but it should be remembered that rotation of the face mechanically 
in this way is very difficult, and much more likely to be attended 
with fatal consequences to the child, than when it is effected by the 
natural efforts. In using forceps for this purpose, the second or 
pelvic curve is likely to prove injurious, and a short straight instru- 
ment is to be preferred. If rotation be found to be impossible, an 
endeavor may be made to draw the face downwards, so as to get the 
chin over the perineum, and deliver in the mento-posterior position ; 
but, unless the child be small, or the pelvis very capacious, the at- 
tempt is unlikely to succeed. Finally, if all these means fail, there 
is no resource left but lessening the size of the head by craniotomy, 
a dernier ressort which, fortunately, is very rarely required. 

Broiv Presentations. — It sometimes happens that the head is par- 
tially extended, so as bring the os frontis into the brim of the pelvis, 
and form what is described as a " brow presentation^ Should the 
head descend in this manner, the difficulties, although not insupera- 
ble, are apt to be very great, from the fact that the long cervico- 
frontal diameter of the head is engaged in the pelvic cavity. The 
diagnosis is not difficult, for the os. frontis will be detected by its 
rounded surface ; while the anterior fontanelle is within reach in 
one direction, the orbit, and root of the nose, in another. 

Spontaneously converted into either Face or Vertex Presentations. — 
Fortunately, in the large majority of cases brow presentations are 
spontaneously converted into either vertex or face presentations, 
according as flexion or extension of the head occurs ; and these must 
be regarded as the desirable terminations and the ones to be favored. 
For this purpose upward pressure must be made on one or other ex- 
tremity of the presenting part during a pain, so as to favor flexion, 
or extension ; or, if the parts be sufficiently dilated, an attempt may 
be made to pass the hand over the occiput and draw it down, thus 
performing cephalic version. The latter is the plan recommended 
by Hodge, who describes the operation as easy. It is questionable, 
however, if a well-marked brow presentation be distinctly made out 
while the head is still at the brim, whether poclalic version would 
not be the easiest and best operation. If the forehead have descended 
too low for this, and if the endeavor to convert it into either a face 
or vertex presentation fail, the forceps will, probably, be required. 
In such cases the face generally turns towards the pubes, the supe- 
rior maxilla becomes fixed behind the pubic arch, and the occiput 
sweeps over the perineum. Yery great difficulty is likely to be ex- 
perienced, and if conversion into either a vertex or face presentation 
cannot be effected, craniotomy is not unlikely to be required. 



DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 307 



CHAPTEE VII. 

DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 

A few words may be said in this place as to the management of 
occipito-jDOSterior positions of the head, especially of those in which 
forward rotation of the occiput does not take place. It has already 
been pointed out that, in the large majority of these cases, the occiput 
rotates forward without any particular difficulty, and the labor termi- 
nates in the usual way, with the occiput emerging under the arch of 
the pubis. 

Rotation Forwards of the Occiput. — In a certain number of cases 
such rotation does not occur, and difficulty and delay are apt to fol- 
low. The proportion of cases in which face to pubis terminations of 
occipito-posterior positions occurs has been variously estimated, and 
they are certainly more common than most of our text-books lead 
us to expect. Dr. Uvedale West, 1 who studied the subject with great 
care, found that labor ended in this way in 79 out of 2585 births, all 
these deliveries being exceptionally difficult. 

Causes of Face to Pubis Delivery. — He believed that forward rota- 
tion of the head is prevented by the absence of flexion of the chin 
on the sternum, so that the long occipito-frontal, instead of the short 
sub-occipito-bregmatic, diameter of the head is brought into contact 
with the pelvic diameter ; hence the occiput is no longer the lowest 
point, and is not subjected to the action of those causes which pro- 
duce forward rotation. Dr. Macdonald, who has written a thoughtful 
paper on the subject, 2 believes that the non-rotation forward of the 
occiput is chiefly due to the large size of the head, in consequence 
of which " the forehead gets so wedged into the pelvis anteriorly 
that its tendency to slacken and rotate forward does not come into 
play." Dr. West's explanation, which has an important bearing on 
the management of these cases, seems to explain most correctly the 
non-occurrence of the natural rotation. 

The important question for us to decide is, how can we best assist 
in the management of cases of this kind when difficulties arise, and 
labor is seriously retarded? 

Mode of Treatment. — Dr. West, insisting strongly on the necessity 
of complete flexion of the chin on the sternum, advises that this 
should be favored by upward pressure on the frontal bone, with the 
view of causing the chin to approach the sternum, and the occiput 
to descend, and thus to come within the action of the agencies which 
favor rotation. Supposing the pains to be strong, and the fontanelle 
to be readily within reach, we may, in this way, very possibly favor 

1 Cranial Presentations, p. 33. 2 Edin. Med. Jour., Oct. 1874. 



308 LABOR. 

the descent of the occiput; and without injuring the mother, or in- 
creasing the difficulties of the case in the event of the manoeuvre 
failing. The beneficial effects of this simple expedient are some- 
times very remarkable. In two cases in which I recently adopted 
it, labor, previously delayed for a length of time without any appa- 
rent progress, although the pains were strong and effective, was in 
each instance rapidly finished almost immediately after the upward 
pressure was applied. The rotation of the face backwards may at 
the same time be favored by pressure on the pubic side of the fore- 
head during the pains. 

Traction on the Occiput. — Others have advised that the descent of 
the occiput should be promoted by downward traction, applied by the 
vectis or fillet. The latter is the plan specially advocated by Hodge; 1 
and the fillet certainly finds one of its most useful applications in 
cases of this kind, as being simpler of application, and probably 
more effective, than the vectis. 

Over-active Endeavors at Assistance should he avoided. — Although 
any of these methods may be adopted, a word of caution is necessary 
against prolonged and over-active endeavors at producing flexion and 
rotation when that seems delayed. All who have watched such cases 
must have observed that rotation often occurs spontaneously at a very 
advanced period of labor, long after the head has been pressed clown 
for a considerable time to the very outlet of the pelvis, and when it 
seems to have been making fruitless endeavors to emerge; so that a 
little patience will often be sufficient to overcome the difficulty. 
[Where the hand of the accoucheur is small, and vaginal outlet suffi- 
ciently large, it may be introduced, and the occiput brought obliquely 
downward and forward by slow degrees, in the intervals between two 
or three pains, until the changed position is secured by uterine con- 
traction. We have executed this movement with great ease, by 
employing the left hand, even in primiparae. A large hand is entirely 
unsuitable. — Ed.] 

When necessary the Forceps may he Used. — In the event of assist- 
ance being absolutely required, there is no reason why the forceps 
should not be used. The instrument is not more difficult to apply 
than under ordinary circumstances, nor, as a rule, is much more trac- 
tion necessary. Dr. Macdonald, indeed, in the paper already alluded 
to, maintains that in persistent occipito-posterior positions there is 
almost always a want of proportion between the head and the pelvis, 
and that, therefore, the forceps will be generally required, and he 
prefers them to any artificial attempts at rectification. Some pecu- 
liarities in the mode of delivery are necessary to bear in mind. In 
most works it is taught, that the operator should pay special atten- 
tion to the rotation of the head, and should endeavor to impart this 
movement by turning the occiput forward during extraction. Thus 
Tyler Smith says, " In delivery with the forceps in occipito-posterior 
presentations, the head should be slowly rotated during the process 
of extraction so as to bring the vertex towards the pubic arch, and 

1 System of Obstetrics, p. 308. 



PRESENTATIONS OF SHOULDER, ETC. 309 

thus convert them into occipitoanterior presentations." The danger 
accompanying any forcible attempt at artificial rotation will, how- 
ever, be evident on slight consideration. It is true that in many 
cases, when simple traction is applied, the occiput will, of itself, ro- 
tate forwards, carrying the instrument with it. But that is a very 
different thing from forcibly twisting round the head with the blades 
of the forceps, without any assurance that the body of the child will 
follow the movement. It is impossible to conceive that such, violent 
interference should not be attended with serious risk of injury to the 
neck of the child. If rotation do not occur, the fair inference is, 
that the head is so placed as to render delivery with, the face to the 
pubis the best termination, and no endeavor should be made to pre- 
vent it. This rule of leaving the rotation entirely to nature, and 
using traction only, has received the approval of Barnes and most 
modern authorities, and is the one which recommends itself as the 
most scientific and reasonable. 

Objection to Curved Instruments in such Cases. — These are cases in 
which the pelvic curve of the forceps is of doubtful utility. "When 
applied in the usual way the convexity of the blades points back- 
wards. If rotation accompany extraction, the blades necessarily 
follow the movement of the head, and their convex edges will turn 
forwards. It certainly seems probable that such a movement would 
subject the maternal soft parts to considerable risk. I have, how- 
ever, more than once seen such rotation of the instrument happen 
without any apparent bad result ; but the dangers are obvious. 
Hence it would be a wise precaution, either to use a pair of straight 
forceps for this particular operation, or to remove the blades and 
leave the case to be terminated by the natural powers, when the head 
is at the lower strait, and rotation seems about to occur. When 
there is no rotation, more than usual care should be taken with the 
perineum, which is necessarily much stretched by the rounded occiput. 
Indeed the risk to the perineum is very considerable, and, even with 
the greatest care, it may be impossible to avoid laceration. 

Bearing these precautions in mind, delivery with the forceps in 
occipito-posterior positions offers no special difficulties or dangers. 



CHAPTER VIII. 

PRESENTATIONS OF THE SHOULDER, ARM, OR TRUNK — COMPLEX 
PRESENTATIONS — PROLAPSE OF THE FUNIS. 

In the presentations already considered the long diameter of the 
foetus corresponded with that of the uterine cavity, and, in all of 
them, the birth of the child by the maternal efforts was the general 
and normal termination of labor. We have now to discuss those 



310 LABOR. 

important cases in which the long diameter of the foetus and uterus 
do not correspond, but in which the long foetal diameter lies ob- 
liquely across the uterine cavity. In the large majority of these it is 
either the shoulder, or some part of the upper extremity, that presents; 
for it is an admitted fact that although other parts of the body, such 
as the back, or abdomen, may, in exceptional cases, lie over the os 
at an early period of labor, yet, as labor progresses, such presenta- 
tions are almost always converted into those of the upper extremity. 

For all practical purposes we may confine ourselves to a considera- 
tion of shoulder presentations ; the further subdivision of these into 
elbow or hand presentations being no more necessary than the division 
of pelvic presentations into breech, knee, and footling cases, since 
the mechanism and management are identical, whatever part of the 
upper extremity presents. 

Delivery by the Natural Powers is quite Exceptional. — There is this 
great distinction between the presentations we are now considering 
and those already treated of, that, on account of the relations of the 
foetus to the pelvis, delivery by the natural powers is impossible, 
except under special and very unusual circumstances that can never 
be relied upon. Intervention on the part of the accoucheur is, there- 
fore, absolutely essential, and the safety of both the mother and 
child depends upon the early detection of the abnormal position of 
the foetus ; for the necessary treatment, which is comparatively easy 
and safe before labor has been long in progress, becomes most diffi- 
cult and hazardous if there have been much delay. 

Position of the Foetus. — Presentations of the upper extremity or 
trunk are often spoken of as " transverse presentations" or " cross 
births ;" but both of these terms are misleading, as they imply that 
the foetus is placed transversely in the uterine cavity, or that it lies 
directly across the pelvic brim. As matter of fact, this is never the 
case, for the child lies obliquely in the uterus, not indeed in its 
long axis, but in one intermediate between its long and transverse 
diameters. 

Divided into Dor so- anterior and Dor so -posterior Positions. — Two 
great divisions of shoulder presentations are recognized ; the one in 
which the back of the child looks to the abdomen of the mother 
(Fig. Ill), and the other in which the back of the child is turned 
towards the spine of the mother (Fig. 112). Each of these is sub- 
divided into two subsidiary classes, according as the head of the 
child is placed in the right or left iliac fossa. Thus in dorso-anterior 
positions, if the head lie in the left iliac fossa, the right shoulder of 
the child presents; if in the right iliac fossa, the left. So in dorso- 
posterior positions, if the head lie in the left iliac fossa, the left 
shoulder present ; if in the right, the right. Of the two classes the 
dorso-anterior positions are more common, in the proportion, it is 
said, of two to one. 

Causes. — The causes of shoulder presentations are not well known. 
Amongst those most commonly mentioned are prematurity of the 
foetus, and excess of liquor amnii ; either of these, by increasing the 
mobility of the foetus in utero, would probably have considerable 



PRESENTATIONS OF SHOULDER, ETC. 



311 



influence. The fact that it occurs much more frequently amongst 
premature births has long been recognized. Undue obliquity of the 



Fig. 111. 




Dorso-anterior Presentation of the Arm. 



uterus has probably some influence, since the early pains might 
cause the presenting part to hitch against the pelvic brim, and the 



Fig. 112. 




Dorso-posterior Presentations of the Arm, 

shoulder to descend. An unusually low attachment of the placenta 
to the inferior segment of the uterine cavity has been mentioned as 
a predisposing cause. In consequence of this the head does not lie 



312 LABOR. 

so readily in the lower uterine segment, and is apt to slip up into 
one of the iliac fossae. This is supposed to explain the frequency of 
arm presentation in cases of partial or complete placenta prgevia. 
Dany ou and Wigand believe that shoulder presentations are favored 
by irregularity in the shape of the uterine cavity, especially a rela- 
tive increase in its transverse diameter. This theory has been gene- 
rally discredited by writers, and it is certainly not susceptible of 
proof; but it seems far from unlikely that some peculiarity of shape 
may exist, not capable of recognition, but sufficient to influence the 
position of the foetus. How otherwise are we to explain those remark- 
able cases, many of which are recorded, in which similar malpositions 
occurred in many successive labors ? Thus Joulin refers to a patient 
who had an arm presentation in three successive pregnancies, and to 
another who had shoulder presentation in three out of four labors. 
Certainly, such constant recurrences of the same abnormality could 
only be explained on the hypothesis of some very persistent cause, 
such as that referred to. It is probable that merely accidental causes 
have most influence in the production of shoulder presentation, such 
as falls, or undue pressure exerted on the abdomen by badly fitting 
or tight stays. Partially transverse positions during pregnancy are 
certainly much more common than is generally believed, and may 
often be detected by abdominal palpation. The tendency is for such 
malpositions to be righted either before labor sets in, or in the early 
period of labor ; but it is quite easy to understand how any persist- 
ent pressure, applied in the manner indicated, may perpetuate a 
position which otherwise would have been only temporor}^. 

Prognosis and Frequency. — According to Churchill's statistics, 
shoulder presentations occur about once in 260 cases, that is only 
slightly less frequently than those of the face. The prognosis to 
both the mother and child is much more unfavorable ; for he esti- 
mates that out of 235 cases 1 in 9 of the mothers, and half the 
children were lost. The prognosis in each individual case will, of 
course, vary much with the period of delivery at which the malposi- 
tion is recognized. If detected early, interference is easy, and the 
prognosis ought to be good ; whereas there are few obstetric diffi- 
culties more trying than a case of shoulder presentation, in which 
the necessary treatment has been delaved until the presenting part 
has been tightly jammed into the cavity of the pelvis. 

Diagnosis. — Bearing this fact in mind, the paramount necessity of 
an accurate diagnosis will be apparent; and it is specially important 
that we should be able not only to detect that a shoulder or arm is 
presenting, but that we should, if possible, determine which it is, and 
how the body and head of the child are placed. The existence of a 
shoulder presentation is not generally suspected, until the first vaginal 
examination is made during labor. The practitioner will then be 
struck with the absence of the rounded mass of the foetal head, and, 
if the os be open and the membranes protruding, by their elongated 
form, which is common to this and to other malpresentatioiis. If 
the presenting part be too high to reach, as is often the case at an 
early period of labor, an endeavor should at once be made to ascer- 



PRESENTATIONS OF SHOULDER, ETC. 313 

tain the foetal position by abdominal examination. This is the more 
important, as it is much more easy to recognize presentations of the 
shoulder in this way than those of the breech or foot; and, at so 
early a period, it is often not only possible, but comparatively easy, 
to alter the position of the foetus by abdominal manipulation alone, 
and thus avoid the necessity of the more serious form of version. 
The method of detecting a shoulder presentation by examination of 
the abdomen has already been described (p. 113), and need not be 
repeated. The chief points to look for are, the altered shape of the 
uterus, and two solid masses, the head and the breech, one in either 
iliac fossa. The facility with which these parts may be recognized 
varies much in different patients. In thin women, with lax abdominal 
parietes, they can be easily felt; while in very stout women, it may 
be impossible. Failing this method, we must rely on vaginal exami- 
nations ; although, before the membranes are ruptured, and when the 
presenting part is high in the pelvis, it is not always easy to gain 
accurate information in this way. The difficulty is increased by the 
paramount importance of retaining the membranes intact as long as 
possible. It should be remembered, therefore, that when a presenta- 
tion of the superior extremity is suspected, the necessary examinations 
should only be made in the intervals between the pains, when the 
membranes are lax, and never when they are rendered tense by the 
uterine contractions. 

As either the shoulder, the elbow, or the hand, may present, it 
will be best to describe the peculiarities of each separately, and the 
means of distinguishing to which side of the body the presenting 
part belongs. 

1. The shoulder is recognized as a round smooth prominence, at 
one point of which may often be felt the sharp edge of the acromion. 
If the finger can be passed sufficiently high, it may be possible to feel 
the clavicle, and the spine of the scapula. A still more complete 
examination may enable us to detect the ribs and the intercostal 
spaces, which would be quite conclusive as to the nature of the 
presentation, since there is nothing resembling them in any other 
part of the body. At the side of the shoulder, the hollow of the 
axilla may generally be made out. 

Mode of Diagnosing the Position of the Child. — In order to ascer- 
tain the position of the child we have to find out in which iliac fossa 
the head lies. This may be done in two ways: 1st, The head may 
be felt through the abdominal parietes by palpation; and 2d, since 
the axilla always points towards the feet, if it point to the left side 
the head must lie in the right iliac fossa, if to the right, the head 
must be placed in the left iliac fossa. Again, the spine of the scapula 
must correspond to the back of the child, the clavicle to its abdomen; 
and, by feeling one or other, we know whether we have to do with 
a dorso-anterior or dorso-posterior position. If we cannot satisfac- 
torily determine the position by these means, it is quite legitimate 
practice to bring down the arm carefully, provided the membranes 
are ruptured, so as to examine the hand, which will be easily recog- 
nized as right or left. This expedient will decide the point; but it 
21 



314 LABOR. 

is one which it is better to avoid, if possible, for it not only slightly 
increases the difficulty of turning, although perhaps not very mate- 
rially, but the arm might possibly be injured in the endeavor to bring 
it down. 

Differential Diagnosis of the Shoulder. — The only part of the body 
likely to be taken for the shoulder is the breech; but in that its 
larger size, the groove in which the genital organs lie, the second 
prominence formed by the other buttock, and the sacral spinous 
processes are sufficient to prevent a mistake. 

2. The elbow is rarely felt at the os, and may be readily recognized 
by the sharp prominence of the olecranon, situated between two lesser 
prominences, the condyles. As the elbow always points towards the 
feet, the position of the foetus can be easily ascertained. 

3. The hand is easy to recognize, and can only be confounded with 
the foot. It can be distinguished by its borders being of the same 
thickness, by the fingers being wider apart and more readily sepa- 
rated from each other than the toes, and above all by the mobility 
of the thumb, which can be carried across the palm, and placed in 
apposition with each of the fingers. 

Mode of Detecting which Hand is Presenting. — It is not difficult to 
tell which hand is presenting. If the hand be in the vagina, or 
beyond the vulva, and within easy reach, we recognize which it is by 
laying hold of it as if we were about to shake hands. If the palm 
lie in the palm of the practitioner's hand, with the two thumbs in 
apposition, it is the right hand ; if the back of the hand, it is the left. 
Another simple way is, for the practitioner to imagine his own hand 
placed in precisely the same position as that of the foetus; and this 
will readily enable him to verify the previous diagnosis. A simple 
rule tells us how the body of the child is placed, for, provided we 
are sure the hand is in a state of supination, the back of the hand 
points to the back of the child, the palm to its abdomen, the thumb 
to the head, and the little finger to the feet. 

Mechanism. — It is perhaps hardly proper to talk of a mechanism 
of shoulder presentations, since, if left unassisted, they almost inva- 
riably lead to the gravest consequences. Still, nature is not entirely 
at fault even here, and it is well to stud}^ the means she adopts to 
terminate these malpositions. 

Terminations. — There are two possible terminations of shoulder 
presentation. In one, known as " spontaneous version." some other 
part of the foetus is substituted for that originally presenting ; in 
the other, " spontaneous evolution" the foetus is expelled by being 
squeezed through the pelvis, without the originally presenting part 
being withdrawn. It cannot be two strongly impressed on the mind 
that neither of these can be relied on in practice. 

Spontaneous version may occasionally occur before, or immediately 
after, the rupture of the membranes, when the foetus is still readily 
movable within the cavity of the uterus. A few authenticated 
cases are recorded in which the same fortunate issue took place after 
the shoulder had been engaged in the pelvic brim for a considerable 
time, or even after prolapse of the arm ; but its probability is neces- 



PRESENTATIONS OF SHOULDER, ETC. 315 

sarily much lessened under such circumstances. Either the head or 
the breech may be brought down to the os in place of the original 
presentation. 

The precise mechanism of spontaneous version, or the favoring 
circumstances, are not sufficiently understood to justify any positive 
statement with regard to it. 

Cazeaux believed that it is produced by partial or irregular con- 
traction of the uterus, one side contracting energetically, while the 
other remains inert, or only contracts to a slight degree. To illus- 
trate how this may effect spontaneous version, let us suppose that 
the child is lving with the head in the left iliac fossa. Then if the 
left side of the uterus should contract more forcibly than the right, 
it would clearly tend to push the head and shoulder to the right side, 
until the head came to present instead of the shoulder. A very in- 
teresting case is related by Geneuil, 1 in which he was present during 
spontaneous version, in the course of which the breech was substi- 
tuted for the left shoulder more than four hours after the rupture of 
the membranes. In this case the uterus was so tightly contracted 
that version was impossible. He observed the side of the uterus 
opposite the head contracting energetically, the other remaining flac- 
cid, and eventually the case ended without assistance, the breech pre- 
senting. The natural moulding action of the uterus, and the greater 
tendency of the long axis of the child to lie in that of the uterus, no 
doubt assist the transformation, and much must depend on the mo- 
bility of the foetus in any individual case. 

That such changes often take place in the latter weeks of preg- 
nancy, and before labor has actually commenced, is quite certain, and 
they are probably much more frequent than is generally supposed. 
When spontaneous version does occur, it is, of course, a most favor- 
able event ; and the termination and prognosis of the labor are then 
the same as if the head or breech had originally presented. 

Spontaneous Evolution. — The mechanism of spontaneous evolution, 
since it was first clearly worked out by Douglas, has been so often 
and carefully described, that we know precisely how it occurs. Al- 
though every now and then a case is recorded in which a living 
child has been born by this means, such an event is of extreme 
rarity; and there is no doubt of the accuracy of the general opinion, 
that spontaneous evolution can only happen when the pelvis is un- 
usually room} r and the child small ; and that it almost necessarily 
involves the death of the foetus, on account of the immense pressure 
to which it is subjected. 

Two varieties are described, in one of which the head is first born, 
in the other the breech ; in both the originally presenting arm re- 
mains prolapsed. The former is of extreme rarity, and is believed 
only to have happened with very premature children, whose bodies 
were small and flexible, and when traction had been made on the 
presenting arm. Under such circumstances it can hardly be called a 

1 Ann. de Gyneclogie, v. v. 1876. 



316 



LABOR. 



natural process, and we may confine our attention to the latter and 
more common variety. 

What takes place is as follows: The presenting arm and shoulder 
are tightly jammed down, as far as is possible, by the uterine con- 
tractions, and the head becomes strongly flexed on the shoulder. As 



Fig. 113. 




Commencing Spontaneous Evolution. 



much of the body of the foetus as the pelvis will contain becomes 
engaged, and then a movement of rotation occurs, which brings the 
body of the child nearly into the antero-posterior diameter of the 
pelvis (Fig. 113). The shoulder now projects under the arch of the 



Fig. 114. 




Spontaneous Evolution further advanced. 



pubis, the head lying above the symphysis, and the breech near the 
sacro-iliac synchondrosis. The shoulder and neck of the child now 



PRESENTATIONS OF SHOULDER, ETC. 317 

become fixed points, round which the body of the child rotates, and 
the whole force of the uterine contractions is expended on the 
breech. The latter, with the body, therefore, becomes more and 
more depressed, until, at last, the side of the thorax reaches the vulva, 
and, followed by the breech and inferior extremities, is slowly pushed 
out (Fig. 114). As soon as the limbs are born the head is easily ex- 
pelled. 

The enormous pressure to which the body is subjected in this 
process can readily be understood. As regards the practical bearings 
of this termination of shoulder presentations, all that need be said 
is, that, if we should happen to meet with a case in which the 
shoulder and thorax were so strongly depressed that turniDg was 
impossible, and in which it seemed that nature was endeavoring to 
effect evolution, we would be justified in aiding the descent of the 
breech by traction on the groin, ^before resorting to the difficult and 
hazardous operation of embryotomy or decapitation. 

Treatment. — It is unnecessary to describe specially the treatment 
of shoulder presentation, since it consists essentially in performing 
the operation of turning, which is fully described elsewhere. It is 
only needful here to insist on the advisability of performing the 
operation in the way which involves the least interference with the 
uterus. Hence if the nature of the case be detected before the mem- 
branes are ruptured, an endeavor should be made — and ought gen- 
erally to succeed — to turn by external manipulation only. If we can 
succeed in bringing the breech or head over the os in this way, the 
case will be little more troublesome than an ordinary presentation 
of these parts. Failing in this, turning by combined external and 
internal manipulation should be attempted ; and the introduction of 
the entire hand should be reserved for those more troublesome cases 
in which the waters have long drained away, and in which both 
these methods are inapplicable. 

Should all these means fail, we have no resource but the mutilation 
of the child by embryulcia or decapitation, probably the most diffi- 
cult and dangerous of all obstetric operations. [In seven instances 
in the United States, where there was no special deformity, the 
Cesarean operation was resorted to, with a saving of life in six of 
the women. The one that died had been 26 hours under a midwife, 
who had administered ergot : death from exhaustion in 12 hours. — 
Ed.] 

Complex Presentations. — There are various so-called complex pre- 
sentations in which more than one part of the foetal body presents. 
Thus we may have a hand or a foot presenting with the head, or a 
foot and hand presenting simultaneously. The former do not neces- 
sarily give rise to any serious difficulty, for there is generally suffi- 
cient room for the head to pass. Indeed it is unlikely that either 
the hand or foot should enter the pelvic brim with the head, unless 
the head was unusually small, or the pelvis more than ordinarily 
capacious. As regards treatment, it is, no doubt, advisable to make 
an attempt to replace the hand or foot by pushing it gently above 
the head in the intervals between the pains, and maintaining it there 



318 



LABOR, 



Fig. 115. 



until the head be fully engaged in the pelvic cavity. The engage- 
ment of the head can be hastened by abdominal pressure, which will 
prove of great value. Failing this, all we can do is to place the 
presenting member at the part of the pelvis where it will least im- 
pede the labor, and be the least subjected to pressure ; and that will 
generally be opposite the temple of the child. As it must obstruct 
the passage of the head to a certain extent, the application of the 
forceps may be necessary. When the feet and hands present at the 
same time, in addition to the confusing nature of the presentation 
from so many parts being felt together, there is the risk of the hands 
coming down, and converting the case into one of arm presentation. 
It is the obvious duty of the accoucheur to prevent this by insuring 
the descent of the feet, and traction should be made on them, either 
with the fingers or with a lac, until their descent, and the ascent of 
the hands, are assured. 

Dorsal Displacement of the Arm, — In connection with this subject 
may be mentioned the curious dorsal displacement of the arm first 
described by Sir James Simpson, 1 in which the forearm of the child 
becomes thrown across and behind the neck. The result is the for- 
mation of a ridge or bar, which prevents the descent of the head into 

the pelvis by hitching against the brim (Fig. 
115). The difficulty of diagnosis is very 
great, for the cause of obstruction is too 
high up to be felt. But if we meet with a 
case in which the pelvis is roomy and the 
pains strong, and yet the head does not de- 
scend after an adequate time, a full explora- 
tion of the cause is essential. For this pur- 
pose we would naturally put the patient 
under chloroform, and pass the hand suffi- 
ciently high. We might then feel the arm 
in its abnormal position. That was what 
took place in a case under my own care, in 
which I failed to get the head through the 
brim with the forceps, and eventually de- 
livered by turning. The same course was 
adopted by my friend Mr. Jardine Murray 
in a similar case. 2 Simpson advises that the 
arm should be brought down so as to con- 
vert the case into an ordinary hand and 
head presentation. This, if the arm be 
above the brim, must always be difficult, 
and I believe the simpler and more effective 
plan is podalic version. A similar displacement may cause some 
difficulty in breech presentations, and after turning (Fig. 116). Delay 
here is easier of diagnosis, since the obstacle to the expulsion will at 
once lead to careful examination. By carrying the body of the child 
well backwards, so as to enable the finger to pass behind- the sym- 




Dorsal Displacement of the Arms. 



Selected Obst. Works, vol. 



Med. Times and Gaz., 1861. 



319 



physis pubis and over the shoulder, it will generally be easy to 
liberate the arm. 

Fig. 116. 




Dorsal Displacement of the Arms in Footling Presentations. (After Barnes.) 

Prolapse of the Umbilical Cord. — It occasionally happens that the 
umbilical cord falls down past the presenting part (Fig. 117), and is 
apt to be pressed between it and the walls of the pelvis. The con- 
sequence ts, that the foetal circulation is seriously interfered with, 
and the death of the child from asphyxia is a common result. Hence 
prolapse of the funis is a very serious complication of labor in so far 
as the child is concerned. 

Frequency. — Fortunately it is not a very frequent occurrence. 
Churchill calculates that out of over 105,000 deliveries it was met 
with --once in 240 cases, and Scanzoni once in 251. Its frequency 
varies much under different circumstances, and in different places. 
We find from Churchill's figures a remarkable difference in the pro- 
portional number of cases observed in France, England, and Germany, 
viz., 1 in 116 J, 1 in 207 J, and 1 in 156, respectively. Great as is 
the proportion referred to Germany in these figures, it has been 
found to be exceeded in special districts. Thus Engelman records 1 
case out of 91 labors in the Lying-in Hospital at Berlin, and Michaelis 
1 in 90 in that of Kiel. These remarkable differences are at first 
sight not easy to account for. Dr. Simpson suggests, with consider- 
able show of probability, that the difference in frequency in England, 



320 



LABOR. 



France, and Germany, may depend on the varying positions in which 
lying-in women are placed during labor in each country. In France, 
where, although the patient is laid on her back, the pelvis is kept 



Fig. 117. 




Prolapse of the Umbilical Cord. 

elevated, the complication occurs least frequently ; in England, where 
she lies on her side, more often ; and in Germany, where she is 
placed on her back with her shoulders raised, most often. The 
special frequency of prolapsed funis in certain districts, as in Kiel, is 
supposed by Engelman 1 to depend on the prevalence of rickets, and 
consequently of deformed pelvis, which we shall presently see is 
probably one of the most frequent and important causes of the 
accident. 

Prognosis. — With regard to the danger attending prolapsed funis, 
as far as the mother is concerned, it may be said to be altogether 
unimportant ; but the universal experience of obstetricians points to 
the great risk to which the child is subjected. Scanzoni calculates 
that 45 per cent, only of the children were saved ; Churchill estimated 
the number at 47 per cent. ; thus, under the most favorable circum- 
stances, this complication leads to the death of more than half the 
children. Engelman found that out of 202 vertex presentations only 
36 per cent, of the children survived. The mortality was not nearly 
so great in other presentations ; Q8 per cent, of the cases in which 
the child presented with the feet were saved, and 50 per cent, in 
original shoulder presentations. The reason of this remarkable dif- 
ference is, doubtless, that in vertex presentations the head tits the 
pelvis much more completely, and subjects the cord to much greater 

1 Amer. Journ. of Obst., vol. vi. 



PRESENTATIONS OF SHOULDER, ETC. 321 

pressure ; while in other presentations the pelvis is less completely 
filled, and the interference with the circulation in the cord is not so 
great. Besides, in the latter case, the complication is detected early, 
and the necessary treatment sooner adopted. 

The foetal mortality is considerably greater in first labors ; a result 
to be expected on account of the greater resistance of the soft parts, 
and the consequent prolongation of the labor. 

Causes. — The causes of prolapse of the funis are any circumstances 
which prevent the presenting part accurately fitting the pelvic brim. 
Hence it is much more frequent in face, breech, or shoulder, than in 
vertex presentations, and is relatively more common in footling and 
shoulder presentations than in any other. Amongst occasional acci- 
dental predisposing causes may be mentioned early rupture of the 
membranes, especially if the amount of liquor amnii be excessive, as 
the sudden escape of the fluid washes down the cord; undue length 
of the cord itself; or an unusually low placental attachment. Engel- 
man attaches great importance to slight contraction of the pelvis, 
and states that in the Berlin Lying-in Hospital, where accurate 
measurements of the pelvis were taken in all cases, it was almost 
invariably found to exist. The explanation is evident, since one of 
the first results of pelvic contraction is to prevent the ready engage- 
ment of the presenting part in the pelvic brim. 

Diagnosis. — The diagnosis of cord presentation is generally devoid 
of difficulty; but if the membranes are still unruptured, it may not 
always be quite easy to determine the precise nature of the soft 
structures felt through them, as they recede from the touch. If the 
pulsations of the cord can be felt through the membranes, all diffi- 
culty is removed. After the membranes are ruptured, there is 
nothing that it can well be mistaken for. 

Importance of Determining the Pulsations of the Cord. — The im- 
portant point to determine in such a case is whether the cord be 
pulsating or not ; for if pulsations have entirely ceased, the inference 
is that the child is dead, and the case may then be left to nature 
without further interference. It is of importance, however, to be 
careful; for, if the examination be made during a pain, the circula- 
tion might be only temporarily arrested. The examination, there- 
fore, should be made during an interval, and a loop of the cord 
pulled down, if necessar}^ to make ourselves absolutely certain on 
this po^nt. 

Amount of Cord Prolapsed. — The amount of the prolapse varies 
much. Sometimes only a knuckle of the cord, so small as to escape 
observation, is engaged between the pelvis and presenting part. 
Under such circumstances the child may be sacrificed without any 
suspicion of danger having arisen. More often the amount pro- 
lapsed is considerable; sometimes so as to lie in the vagina in a long 
loop, or even to protrude altogether beyond the vulva. 

Treatment. — In the treatment the great indication is to prevent the 
corcl from being unduly pressed on, and all our endeavors must have 
this object in view. If the presentation be detected before the full 
dilatation of the cervix, and when the membranes are unruptured, 



322 



LABOR. 



we must try to keep the cord out of the way ; to preserve the mem- 
branes intact as long as possible, since the cord is tolerably protected 
as long as it is surrounded by the liquor amnii ; and to secure the 
complete dilatation of the os, so that the presenting part may engage 
rapidly and completely. 

Postural Treatment. — Much may be done at this time by the pos- 
tural treatment, which we chiefly owe to the ingenuity of Dr. Gail- 
lard Thomas, of New York, whose writings familiarized the profession 
with it, although it appears that a somewhat similar plan had been 
occasionally adopted previously. Dr. Thomas's method is based on 
the principle of causing the cord to slip back into the uterine cavity 
by its own weight. For this purpose the patient is placed on her 
hands and knees, with the hips elevated, and the shoulders resting 
on a lower level (Fig. 118). The cervix is then no longer the most 

Fig. 118. 




Postural Treatment of Prolapse of the Cord. 



dependent portion of the uterus, and the anterior wall of the uterus 
forms an inclined plane down which the cord slips. The success of 
this manoeuvre is sometimes very great, but by no means always so. 
It is most likely to succeed when the membranes are unruptured. 
If, when adopted, the cord slip away, and the os be sufficiently dilated, 
the membranes may be ruptured, and engagement of the head pro- 
duced by properly applied uterine pressure. Sometimes the position 
is so irksome that it is impossible to resort to it. Postural treatment 
is not even then altogether impossible, for by placing the patient on 
the side opposite to that of the prolapse, so as to relieve the cord as 
much as possible from pressure, and at the same time elevating the 
hips by a pillow, it may slip back. Even after the membranes are 
ruptured, postural treatment in one form or another may succeed ; 
and, as it is simple and harmless, it should certainly be always tried. 
Attempts at reposition, by one or other of the methods described 
below, may also occasionally be facilitated by trying them when the 
patient is placed in the knee-shoulder position. 



PRESENTATIONS OF SHOULDER, ETC. 



323 



Fig. 119. 



Artificial Reposition. — Failing by postural treatment, or in combi- 
nation with it, it is quite legitimate to make an attempt to place the 
cord beyond the reach of dangerous pressure by other methods. 
Unfortunately reposition is too often disappointing, difficult to effect, 
and very frequently, even when apparently successful, shortly 
followed by a fresh descent of the cord. Provided the os be fully 
dilated, and the presenting head engaged in the pelvis (for reposition 
may be said to be hopeless when any other part presents), perhaps 
the best way is to attempt it by the hand alone. Probably the 
simplest and most effectual method is that recommended by McClin- 
tock and Hardy, who advise that the patient 
should lie on the opposite side to the prolapsed 
cord, which should then be drawn towards the 
pubis as being the shallowest part of the pelvis. 
Two or three fingers may then be used to push 
the cord past the head, and as high as they can 
reach. They must be kept in the pelvis until a 
pain comes on, and then very gently withdrawn, 
in the hope that the cord may not again prolapse. 
During the pain external pressure may very 
properly be applied to favor descent of the head. 
This manoeuvre may be repeated during several 
successive pains, and may eventually succeed. 
The attempt to hook the cord over the foetal limbs, 
or to place it in the hollow of the neck, recom- 
mended in many works, involves so deep an in- 
troduction of the hand, that it is obviously im- 
practicable. 

Instruments Used for Reposition. — Various com- 
plex instruments have been invented to aid repo- 
sition (Fig. 119), but even if we possessed them, 
they are not likely to be at hand when the emer- 
gency arises. A simple instrument may be im- 
provised out of an ordinary male elastic catheter, 
by passing the two ends of a piece of string 
through it, so as to leave a loop emerging from 
the eye of the catheter. This is passed through 
the loop of prolapsed cord, and then fixed in the 
eye of the catheter by means of the stilette. The 
cord is then pushed up into the uterine cavity by the catheter, and 
liberated by withdrawing the stilette. Another simple instrument 
may be made by cutting a hole in a piece of whalebone. A piece of 
tape is then passed through the loop of the cord, and the ends threaded 
through the eye cut in the whalebone. By tightening the tape the 
whalebone is held in close apposition to the cord, and the whole is 
passed as high as possible into the uterine' cavity. The tape can 
easily be liberated by pulling one end. If preferred, the cord can be 
tied to the whalebone, which is left in utero until the child is born. 
Nothing need be said as to the various other methods adopted for 
keeping up the cord, such as the insertion of pieces of sponge, or 




Braun's Apparatus for 
Keplacing the Cord. 



324 LABOR. 

tying the cord in a bag of soft leather, since they are generally ad- 
mitted to be quite useless. 

Treatment when Reposition Fails. — It only too often happens that 
all endeavors at reposition fail. The subsequent treatment must 
then be guided by the circumstances of the case. If the pelvis be 
roomy, and the pains strong, especially in a multipara, we may often 
deem it advisable to leave the case to nature, in the hope that the 
head may be pushed through before pressure on the cord has had 
time to prove fatal to the child. Under such circumstances the 
patient should be urged to bear down, and the descent of the head 
promoted by uterine pressure, so as to get the second stage com- 
pleted as soon as possible. If the head be within easy reach, the 
application of the forceps is quite justifiable, since delay must neces- 
sarily involve the death of the child. During this time the cord 
should be placed, if possible, opposite one or other sacro-iliac syn- 
chondrosis, according to the position of the head, as the part of the 
pelvis where there is most room, and where the pressure would conse- 
quently be least prejudicial. If we have to do with a case in which 
the head has not descended into the pelvis, and postural treatment 
and reposition have both failed, provided the os be fully dilated, and 
other circumstances be favorable, turning would undoubtedly offer 
the best chance to the child. This treatment is strongly advocated 
by Engelman, who found that 70 per cent, of the children delivered 
in this way were saved. There can be no question that, so far as the 
interests of the child are concerned, it is, under the circumstances 
indicated, by far the best expedient. Turning, however, is by no 
means always devoid of a certain risk to the mother, and the per- 
formance of the operation, in any particular case, must be left to the 
judgment of the practitioner. A fully dilated os, with membranes 
unruptured, so that version could be performed by the combined 
method without the introduction of the hand into the uterus, would 
be unquestionably the most favorable state. If it be not deemed 
proper to resort to it, all that can be done is to endeavor to save the 
cord from pressure as much as possible, by one or other of the 
methods already mentioned. 



CHAPTEK IX. 

PROLONGED AND PRECIPITATE LABORS. 

Amono the difficulties connected with parturition there are none 
of more frequent occurrence, and none requiring more thorough 
knowledge of the physiology and pathology of labor, than those 
arising from deficient or irregular action of the expulsive powers. 



PROLONGED AND PRECIPITATE LABORS, 325 

The importance of studying this class of labors will be seen when we 
consider the numerous and very diverse causes which produce them. 

Evil Effects of Prolonged Labor. — That the mere prolongation of 
labor is in itself a serious thing, is becoming daily more and more an 
acknowledged axiom of midwifery practice ; and that this is so is 
evident when we contrast the statistical returns of such institutions 
as the Rotunda Lying-in Hospital of late years, with those which 
were published some twenty or thirty years ago. It may be fairly 
assumed that the practice of the distinguished heads of that well- 
known school represents the most advanced and scientific opinion of 
the day. When we find that, less than thirty years ago, the forceps 
were not used more than once in 310 labors, while according to the 
report for 1873 the late Master applied them once in 8 labors, it is 
apparent how great is the change which has taken place. 

Causes of Prolonged Labor. — Labor may be prolonged from an 
immense number of causes, the principal of which will require sepa- 
rate study. Some depend simply on defective or irregular action of 
the uterus ; others act by opposing the expulsion of the child, as, for 
example, undue rigidity of the parturient passages, tumors, bony 
deformity, and the like. AVhatever the source of delay, a train of 
formidable symptoms are developed, which are fraught with peril 
both to the mother and the child. As regards the mother, they vary 
much in degree, and in the rapidity with which they become estab- 
lished. In many cases, in which the action of the uterus is slight, it 
may be long before serious results follow ; while in others, in which 
a strongly-acting organ is exhausting itself in futile endeavors to- 
overcome an obstacle, the worst signs of protraction may come on 
with comparative rapidity. 

The Lnfluence of the Stage of Labor in Protraction. — The stage of' 
labor in which delay occurs has a marked effect in the production of' 
untoward symptoms. It is a well-established fact that prolongation 
is of comparatively small consequence to either the mother or child: 
in the first stage, when the membranes are still intact, and when the 
soft parts of the mother, as well as the body of the child, are pro- 
tected by the liquor amnii from injurious pressure; whereas • if' the 
membranes have ruptured, prolongation becomes of the utmost im- 
portance to both as soon as the head has entered the pelvis, when 
the uterus is strongly excited by reflex stimulation, when the mater- 
nal soft parts are exposed to continuous pressure, and when the 
tightly-contracted uterus presses firmly on the foetus and obstructs 
the placental circulation. It is in reference to the latter class of cases 
that the change of practice, already alluded to, has taken place, with: 
the most beneficial results both to the mother and child. 

It must not be assumed, however, that prolongation of labor is 
never of any consequence until the second stage has commenced.. 
The fallacy of such an opinion was long ago shown by Simpson, who 
proved, in the most conclusive way, that both the maternal and foetal 
mortality were greatly increased in proportion to the entire length 
of the labor ; and all practical accoucheurs are familiar with cases in. 
which symptoms of gravity have arisen before the first stage is- 



326 LABOR. 

concluded. Still, relatively speaking, the opinion indicated is un- 
doubtedly correct. 

In the present chapter we have to do only with those causes of 
delay connected with the expulsive powers. Inasmuch, however, as 
the injurious effects of protraction are similar in kind, whatever be 
the cause, it will save needless repetition if we consider, once for all, 
the train of symptoms that arise whenever labor is unduly prolonged. 

Delay in the First Stage. — As long as the delay is in the first stage 
only, with rare exceptions, no symptoms of real gravity arise for a 
length of time ; it may be even for days. There is often, however, 
a partial cessation of the pains, which, in consequence of temporary 
exhaustion of nervous force, may even entirely disappear for many 
consecutive hours. Under such circumstances, after a period of rest, 
either natural or produced by snitable sedatives, they recur with 
renewed vieror. 

Symptoms of Protraction in the Second Stage. — A similar temporary 
cessation of the pains may often be observed after the head has 
passed through the os uteri, to be also followed by renewed vigorous 
action after rest. But now any such irregularity must be much more 
anxiously watched. In the majority of cases any marked alteration 
in the force and frequency of the pains at this period indicates a 
much more serious form of delay, which in no long time is accom- 
panied by grave general symptoms. The pulse begins to rise, the 
skin to become hot and dry, the patient to be restless and irritable. 
The longer the delay, and the more violent the efforts of the uterus 
to overcome the obstacle, the more serious does the state of the 
patient become. The tongue is loaded with fur, and, in the worst 
cases, dry and black ; nausea and vomiting often become marked ; 
the vagina feels hot and drj^, the ordinar} T abundant mucous secre- 
tion being absent ; in severe cases it may be much swollen, and if 
the presenting part be firmly impacted, a slough may even form. 
Should the patient still remain undelivered, all these symptoms be- 
come greatly intensified ; the vomiting is incessant, the pulse is rapid 
and almost imperceptible, low muttering delirium supervenes, and 
the patient eventually dies with all the. worst indications of profound 
irritation and exhaustion. 

So formidable a train of symptoms, or even the slighter degrees of 
them, should never occur in the practice of the skilled obstetrician ; 
and it is precisely because a more scientific knowledge of the process 
of parturition has taught the lesson that, under such circumstances, 
prevention is better than cure, that earlier interference has become so 
much more the rule. 

Those who taught that nothing should be done until nature had 
had every possible chance of effecting delivery, and who, therefore, 
allowed their patients to drag on in many weary hours of labor, at 
the expense of great exhaustion to themselves, and imminent risk to 
their offspring, made much capital out of the time-honored maxim 
that " meddlesome midwifery is bad." When this proverb is applied 
to restrain the rash interference of the ignorant, it is of undeniable 
value ; but, when it is quoted to prevent the scientific action of the 



PROLONGED AND PRECIPITATE LABORS. 327 

experienced, who know precisely when and why to interfere, and 
who have acquired the indispensable mechanical skill, it is sadly 
misapplied. 

State of the Uterus in Protracted Labor. — The nature of the pains 
and the state of the uterus, in cases of protracted labor, are peculiarly 
worthy of study, and have been very clearly pointed out by Dr. 
Braxton Hicks. 1 He shows that, when the pains have apparently 
fallen off and become few and feeble, or have entirely ceased, the 
uterus is in a state of continuous or tonic contraction, and that the 
irritation resulting from this is the chief cause of the more marked 
symptoms of powerless labor. If, in a case of the kind, the uterus be 
examined by palpation, it will be found firmly contracted between 
the pains. The correctness of this observation is beyond question, 
and it will, no doubt, often be an important guide in treatment. 
Under such circumstances instrumental interference is imperatively 
demanded. 

Conditions and Causes affecting the Expulsive Poivers. — In consider- 
ing the causes of protracted labor, it will be well first to discuss those 
which affect the expulsive powers alone, leaving those depending on 
morbid states of the passages for future consideration ; bearing in 
mind, however, that the results, as regards both the mother and the 
child, are identical, whatever may be the cause of delay. 

Constitution of the Patient. — The general constitutional state of the 
patient may materially influence the force and efficiency of the pains. 
Thus it not unfrequently happens that they are feeble and ineffective 
in women of very weak constitution, or who are much exhausted by 
debilitating disease. Cazeaux pointed out that the effects of such 
general conditions are often more than counterbalanced by flaccidity 
and want of resistance of the tissues, so that there is less obstacle to 
the passage of the child. Thus in phthisical patients reduced to the 
last stage of exhaustion, the labor is not unfrequently surprisingly 
easy. 

Influence of Tropical Climates. — Long residence in tropical climates 
causes uterine inertia, in consequence of the enfeebled nervous power 
it produces. It is a common observation that European residents in 
India are peculiarly apt to suffer from post-partum hemorrhage from 
this cause. The general mode of life of patients has an unquestion- 
able effect ; and it is certain that deficient and irregular uterine action 
is more common in women of the higher ranks of society, who lead 
luxurious, enervating lives, than in women whose habits are of a 
more healthy character. 

Frequent Child-hearing. — Tyler Smith lays much stress on frequent 
child-bearing as a cause of inertia, pointing out that a uterus which. 
has been very frequently subjected to the changes connected with 
pregnancy, is unlikely to be in a typically normal condition. It is 
doubtful, however, whether the uterus of a perfectly healthy woman 
is affected in this way ; certainly, if child-bearing had undermined 
her general health, the labors are likely to be modified also. 

1 Obst. Trans., vol. ix. 



328 LABOR. 

Age of Patient. — Age has a decided effect. In the very young the 
pains are apt to be irregular, on account of imperfect development 
of the uterine muscle. Labor taking place for the first time in 
women advanced in life is also apt to be tedious, but not by any 
means so invariably as is generally believed. The apprehensions of 
such patients are often agreeably falsified, and where delay does 
occur, it is probably more often referable to rigidity and toughness 
of the paturient passages than to feebleness of the pains. 

Disorders of the Intestines. — Morbid states of the primae vice fre- 
quently cause irregular, painful, and feeble contractions. A loaded 
state of the rectum has often a remarkable influence, as evidenced 
by the sudden and distinct change in the character of the labor which 
often follows the use of suitable remedies. Undue distension of the 
bladder often acts in the same way, more especially in the second 
stage. When the urine has been alloAved to accumulate unduly, the 
contraction of the accessory muscles of parturition often causes such 
intense suffering, by compressing the distended viscus, that the pa- 
tient is absolutely unable to bear down. Hence the labor is carried 
on by uterine contractions alone, slowly, and at the expense of much 
suffering. A similar interference with the action of the accessory 
muscles is often produced by other causes. Thus if labor comes on 
when the patient is suffering from bronchitis or other chest disease, 
she may be quite unable to fix the chest by a deep inspiration, and 
the diaphragm and other accessory muscles cannot act. In the same 
way they may be prevented from acting when the abdomen is occu- 
pied by an ovarian tumor, or by ascitic fluid. 

Mental conditions have a very marked effect. This is so commonly 
observed that it is familiar to the merest beginner in midw T ifery prac- 
tice. The fact that the pains often diminish temporarily on the 
entrance of the accoucheur is known to every nurse ; and so also 
undue excitement, the presence of too many people in the room, 
over-much talking, have often the same prejudicial effect. Depres- 
sion of mind, as in unmarried women, and fear and despondency in 
women who have looked forward with apprehension to their labor, 
are also common causes of irregular and defective action. 

Excessive Amount of Liquor Amnii. — Undue distension of the uterus 
from an excessive amount of liquor amnii not unfrequently retards 
the first stage, by preventing the uterus from contracting efficiently. 
When this exists, the pains are feeble and have little effect in dilating 
the cervix beyond a certain degree. This cause may be suspected, 
when undue protraction of the first stage is associated with an unusu- 
ally large size and marked fluctuation of the uterine tumor, through 
which the foetal limbs cannot be made out on palpation. On vaginal 
examination, the lower segment of the uterus will be found to be 
very rounded and prominent, while the bag of membranes will not 
bulge through the os during the acme of the pain. 

Malpositions of the Uterus. — A somewhat similar cause is undue 
obliquity of the uterus, which prevents the pains acting to the best 
mechanical advantage, and often retards the entry of the presenting 
part into the brim. The most common variety is anteversion, result- 



PROLONGED AND PRECIPITATE LABORS. 329 

ing from excessive laxity of the abdominal parietes, which is espe- 
cially found in -women who have borne many children. Sometimes 
this is so excessive that the fundus lies over the pubis, and even 
projects downwards towards the patient's knees. The consequence 
is that, when labor sets in, unless corrective means be taken, the 
pains force the head against the sacrum, instead of directing it into 
the axis of the pelvic inlet. Another common deviation is lateral 
obliquity, a certain degree of which exists in almost all cases, but 
sometimes it occurs to an excessive degree. Either of these states 
can readily be detected by palpation and vaginal examination com- 
bined. In the former the os may be so high up, and tilted so far 
backwards, that it may be at first difficult to reach it at all. 

Irregular and Spasmodic Pains. — Besides being feeble, the uterine 
contractions, especially in the first stage, are often irregular and 
spasmodic, intensely painful, but producing little or no effect on the 
progress of the labor. This kind of case has been already alluded 
to in treating of the use of anaesthetics (p. 283), and is very com- 
mon in highly nervous and emotional women of the upper classes. 
Such irregular contractions do not necessarily depend on mental 
causes alone, and they are often produced by conditions producing 
irritation, such as loaded bowels, too early rupture of the membranes, 
and the like. Dr. Trenholme, of Montreal, 1 believes that such irregu- 
lar pains most frequently depend on abnormal adhesions between 
the decidua and the uterine Avails, which interfere with the proper 
dilatation of the os, and he has related some interesting cases in 
support of this theory. 

Treatment. — The mere enumeration of these various causes of pro- 
tracted labor will indicate the treatment required. Some of them, 
such as the constitutional state of the patient, age, or mental emotion, 
it is, of course, beyond the power of the practitioner to influence or 
modify; but in every case of feeble or irregular uterine action, a 
careful investigation should be made with the view of seeing if any 
removable cause exist. For example, the effect of a large enema, 
when we suspect the existence of a loaded rectum, is often very re- 
markable ; the pains frequently almost immediately changing in 
character, and a previously lingering labor being rapidly terminated. 

Excessive distension of the uterus can only be treated by artificial 
evacuation of the liquor amnii ; and after this is done, the character 
of the pains often rapidly changes. This expedient is indeed often 
of considerable value in cases in which the cervix has dilated to a 
certain extent, but in which no further progress is made, especially 
if the bag of membranes does not protrude through the os during 
the pains, and the cervix itself is soft, and apparently readily dilata- 
ble. Under such circumstances, rupture of the membranes, even 
before the os is fully dilated, is often very useful. 

Adherent Membranes. — If we have reason to suspect morbid adhe- 
sions between the membranes and the uterine walls, an endeavor 
must be made to separate them by sweeping the finger or a flexible 

1 Obst. Trans. 1873. 

22 



330 LABOR. 

catheter round the internal margin of the os, or puncturing the sac. 
The former expedient has been advocated by Dr. Inglis, 1 as a means 
of increasing the pains when the first stage is very tedious, and I 
have often practised it with marked success. Trenholme's observa- 
tion affords a rationale of its action. The manoeuvre itself is easily 
accomplished, and, provided the os be not very high in the pelvis, 
does not give any pain or discomfort to the patient. 

Uterine Deviations. — Attention should always be paid to remedy- 
ing any deviation of the uterus from its proper axis. If this be 
lateral, the proper course to pursue is to make the patient lie on the 
opposite side to that towards which the organ is pointing. In the 
more common anterior deviation she should lie on her back, so that 
the uterus may gravitate towards the spine, and a firm abdominal 
bandage should be applied. This prevents the organ from falling 
forwards, while its pressure stimulates the muscular fibres to increased 
action ; hence it is often Yery serviceable when the pains are feeble, 
even if there be no ante version. 

Temporary Exhaustion. — In a frequent class of cases, especially in 
the first stage, the pains diminish in force and frequency from fatigue, 
and the indication then is to give a temporary rest, after which they 
recommence with renewed vigor. Hence an opiate, such as 20 
minims of Battley's solution, which often acts quickest when given 
in the form of enema, is frequently of the greatest possible value. 
If this secure a few hours' sleep, the patient will generally awake 
much refreshed and invigorated. It is important to distinguish this 
variety of arrested pain from that dependent on actual exhaustion ; 
and this can be done by attention to the general condition of the 
patient, and especially by observing that the uterus is soft and flaccid 
in the intervals between the pains, and that there is none of the tonic 
contraction, indicated by persistent hardness of the uterine parietes. 
When the pains are irregular, spasmodic, and excessively painful, 
without producing any real effect, opiates are also of great service ; 
and it is under such circumstances that chloral is especially valuable. 

Oxytocic Remedies. — Still a large number of cases will arise in 
which the absence of all removable causes has been ascertained, and 
in which the pains are feeble and ineffective. We must now proceed 
to discuss their management. The fault being the want of sufficient 
contraction, the first indication is to increase the force of the pains. 
Here the so-called oxytocic remedies come into action ; and, although 
a large number of these have been used from time to time, such as 
borax, cinnamon, 2 quinine, and galvanism, practically, the only one 

1 Sydenham Society's Year-Book, 18G9. 

2 [Quinia as an oxytocic deserves more than a passing notice, having been very 
carefully tested by several leading obstetricians of Philadelphia within a few years. 
According to the observations of Dr. Albert H. Smith, in 42 cases of parturition, it 
presents the following peculiar characteristics. 

It has no power in itself to excite uterine contractions, but simply acts as a general 
stimulant, and promoter of vital energy, and functional activity. 

In normal labor at full term, its administration in a dose of fifteen grains, is usually 
folloAved in as many minutes by a decided increase in the force and frequency of the 



PROLONGED AND PRECIPITATE LAEORS. 331 

in which any reliance is now placed is the ergot of rye. This has 
long been the favorite remecty for deficient uterine action, and it is a 
powerful stimulant of the uterine fibres. It has, however, very 
serious disadvantages, and it is very questionable whether the risks 
to both mother and child do not more than counterbalance any ad- 
vantages attending its use. The ergot is given in doses of 15 or 20 
grains of the freshly powdered drug diffused in warm water, or in 
the more convenient form of the liquid extract, in doses of from 20 
to 30 minims. In about fifteen minutes after its administration the 
pains generally increase greatly in force and frequency, and if the 
head be low in the pelvis, and if the soft parts offer no resistance, 
the labor may be rapidly terminated. 

Objections to its Use. — \Yere its use always followed by this effect 
there would be little or no objection to its administration. The pains, 
however, are different from those of natural labor, being strong, per- 
sistent, and constant. Its effect, indeed, is to produce that very state 
of tonic and persistent uterine contraction, which has been already 
pointed out as one of the chief dangers of protracted labor. Hence 
if, from any cause, the exhibition of the drug be not followed by rapid 
delivery, a condition is produced which is serious to the mother ; 
and which is extremely perilous to the child, on account of the tonic 
contraction of the muscular fibres obstructing the utero-placental 
circulation. Dr. Hard} r found that soon the foetal pulsations fall to 
100, and, if delivery be long delayed, they commence to intermit. 
He also observed that when this occurred the child was always born 
dead, and found that the number of still-born children after ergot 
has been exhibited was very large ; for out of 30 cases in which he 
gave it in tedious labor, only 10 of the children were born alive. 
Nor is its use by any means free from danger to the mother ; a not 
inconsiderable number of cases of rupture of the uterus have been 
attributed to its incautious use. Hence, if it is to be given at all, it 
is obvious that it must be with strict limitations, and after careful 
consideration. 

Limitations to its Use. — The cardinal point to remember is that it 
is absolutely contra-indicated unless the absence of all obstacles to 
rapid delivery has been ascertained. 1 Hence, it is only allowable 
when the first stage is over, and the os fully dilated ; when the ex- 
perience of former labors has proved the pelvis to be of ample size ; 
and when the perineum is soft and dilatable. Perhaps, as has been 

uterine contractions, changing in some instances a tedious exhausting labor, into one 
of rapid energy, advancing to an early completion. 

It promotes the permanent tonic contraction of the uterus, after the expulsion of 
the placenta; women that had flooded in former labors, escaping entirely, there not 
having been an instance of post-partum hemorrhage in the whole 42 cases, 

It also diminishes the lochial flow where it had been excessive in former labors, the 
change being remarked upon by the patients ; and consequently lessens the severity 
of the after-pains. 

Cinchonism is very rarely observed as an effect of large doses in parturient women. — 
Ed.— Trans. Coll.' ' Phys. Phila. 1875, p. 183.] 

1 [We cannot be too cautious in using, or recommending the use of ergot. For- 
tunately we can accomplish much with the use of quinia. See page 3t30. — Ed.] 



332 LABOR. 

suggested, the administration of small doses of from 5 to 10 minims 
of the liquid extract every ten minutes, until more energetic action 
set in, might obviate some of these risks. 

Manual Pressure as a Means of Increasing the Uterine Contractions. 
— If we had no other means of increasing defective uterine contrac- 
tions at oar disposal, and if the choice lay only between the use of 
ergot and instrumental delivery, there might not be so much objec- 
tion to a cautious use of the drug in suitable cases. We have, how- 
ever, a means of increasing the force of the uterine contractions so much 
more manageable, and so much more resembling the natural process, 
that I believe it to be destined to entirely supersede the administration 
of ergot. This is the application of manual pressure to the uterus 
through the abdomen, an expedient that has of late years been much 
used in Germany, and has begun to be employed in English practice. 
I believe, therefore, that ergot should be chiefly used for the purpose 
of exciting uterine contraction after delivery, when its peculiar 
property of promoting tonic contraction is so valuable, and that it 
should rarely, if at all, be employed before the birth of the child. 

The systematic use of uterine pressure as an oxytocic was first 
prominently brought under the notice of the profession by Kristeller, 
under the name of " Expressio Foetus," although it has been used in 
various forms from time immemorial. Albucasis, for example, was 
clearly acquainted with its use, and referred to it in the following 
terms : " Cum ergo vides ista signa, tunc oportet, ut comprimatur 
uterus ejus ut descendat embryo velociter." There are some curious 
obstetric customs among various nations, which probably arose from 
a recognition of its value ; as, for example, the mode of delivery 
adopted among the Kalmucks, where the patient sits at the foot of 
the bed, while a woman, seated behind her, seizes her round the waist 
and squeezes the uterus during the pains. Amongst the Japanese, 
Siamese, North American Indians, and many other nations, pressure, 
applied in various ways, is habitually used. 

Kristeller maintains that it is possible to effect the complete ex- 
pulsion of the child by properly applied pressure, even when the 
pains are entirely absent. Strange as this may appear to those who 
are not familiar with the effects of pressure, I believe that, under 
exceptional circumstance, when the pelvis is very capacious, and the 
soft parts offer but slight resistance, it can be done. I have delivered 
in this way a patient whose friends would not permit me to apply 
the forceps, when I could not recognize the existence of any uterine 
contraction at all, the foetus being literally squeezed out of the uterus. 
It is not, however, as replacing absent pains, but as a means of in- 
tensifying and prolonging the effects of deficient and feeble ones, that 
pressure finds its best application. 

Its effects are often very remarkable, especially in women of slight 
build, where there is but little adipose tissue in the abdominal walls, 
and not much resistance in the pelvic tissues. If the finger be placed 
on the head while pressure is applied to the uterus, a very marked 
descent can readily be felt, and not infrequently two or three appli- 
cations will force the head on to the perineum. There are, however, 



PROLONGED AND PRECIPITATE LABORS. 333 

certain conditions when it is inapplicable, and the existence of which 
should contra-inclicate its use. Thus if the uterus seem uu usually 
tender on pressure, and, a fortiori, if the tonic contraction of ex- 
haustion he present, it is inadmissible. So also if there be any ob- 
struction to rapid delivery, either from narrowing of the pelvis or 
rigidity of the soft parts, it should not be used. The cases suitable 
for its application are those in which the head or breech is in the 
pelvic cavity, and the delay is simply due to a want of sufficiently 
strong expulsive action. 

Mode of Application. — It may be applied in two ways. The better 
is to place the patient on her back at the edge of the bed, and spread 
the palms of the hands on either side of the fundus and body of the 
uterus, and, when a pain commences, to make firm pressure during 
its continuance downwards and backwards in the direction of the 
pelvic inlet. As the contraction passes off the pressure is relaxed, 
and again resumed when a fresh pain begins. In this way each pain 
is greatly intensified, and its effect on the progress of the foetus much 
increased. It is not essential that the patient should lie on her back. 
A useful, although not so great, amount of pressure can be applied 
when she is lying in the ordinary obstetric position on her left side, 
the left hand being spread out over the fundus, leaving the right free 
to watch the progress of the presenting part per vaginam. 

Special Value of Uterine Pressure.- — The special value of this 
method of treating ineffective pains is, that the amount and fre- 
quency of the pressure are completely within the control of the 
practitioner, and are capable of being regulated to a nicety in ac- 
cordance with the requirements of each particular case. It has the 
peculiar advantage of closely imitating the natural means of delivery, 
and of being absolutely without risk to the child : nor is there any 
reason to think that it is capable of injuring the mother. At least I 
may safely say that, out of the large number of cases in which I 
have used it, I have never seen one in which I had the least reason 
to think that it had proved hurtful. Of course, it is essential not to 
use undue roughness : firm and even strong pressure may be em- 
ployed, but that can be done without being rough ; and, as its appli- 
cation is always intermittent, there is no time for it to inflict any 
injury on the uterine tissues. 

Pressure is specially valuable when it is desirable to intensify 
feeble pains. It may be serviceably employed when the pains are 
altogether absent, to imitate and replace them, provided there be 
nothing but the absence of a vis a tercjo to prevent speedy delivery. 
In such cases an endeavor should be made to imitate the pains as 
closely as possible, by applying the pressure at intervals of four or 
five minutes, and entirely relaxing it after it has been applied for a 
few seconds. 

Change of Professional Opinion as to Instrumental Delivery. — 
When all these means fail we have then left the resource of instru- 
mental aid, and we have now to consider the indications for the use 
of the forceps under such circumstances. It has been already pointed 



334 LABOR. 

out that professional opinion on this point has been undergoing a 
marked change ; and that it is now recognized as an axiom by the 
most experienced teachers that, when we are once convinced that the 
natural efforts are failing, and are unlikely to effect delivery, except 
at the cost of long delay, it is far better to interfere soon rather than 
late, and thus prevent the occurrence of the serious symptoms ac- 
companying protracted labor. This is, of course, a practice directly 
opposed to that so long taught in our standard works, in which in- 
strumental interference was strictly prohibited unless all hope of 
natural delivery was at end ; and in which the commencement at 
least, if not the complete establishment, of symptoms of exhaustion, 
was considered to be the only justification for the application of for- 
ceps in lingering labor. 

Views of Dr. Johnston on the Use of the Forceps. — 'The reasons which 
have led the late distinguished Master of the Eotunda Hospital to a 
more frequent use of the forceps are so well expressed in his report 
for 1872, that I venture to quote them, as the best j ustification for a 
practice that many practitioners of the older school will, no doubt, 
be inclined to condemn as rash and hazardous. He says: 1 "Our 
established rule is that so long as nature is able to effect its purpose 
without prejudice to the constitution of the patient, danger to the 
soft parts, or the life of the child, we are in duty bound to allow the 
labor to proceed ; but as soon as we find the natural efforts are be- 
ginning to fail, and after having tried the milder means for relaxing 
the parts or stimulating the uterus to increased action, and the de- 
sired effects not being produced, we consider we are in duty bound 
to adopt still prompter measures, and by our timely assistance relieve 
the sufferer from her distress and her offspring from an imminent 
death. Why, may I ask, should we permit a fellow creature to 
undergo hours of torture when we have the means of relieving them 
within our reach ? Why should she be allowed to waste her strength, 
and incur the risks consequent upon long pressure of the head on the 
soft parts, the tendency to inflammation and sloughing, or the danger 
of rupture, not to speak of the poisonous miasm which emanates 
from an inflammatory state of the passages, the result of tedious 
labor, and which is one of the fertile causes of puerperal fever and 
all its direful effects, attributed by some to the influence of being 
confined in a large maternity, and not to its proper source, i. e., the 
labor being allowed to continue till inflammatory symptoms appear. 
The more we consider the benefits of timely interference, and the 
good results which follow it, the more are we induced to pursue the 
system we have adopted, and to inculcate to those we are instructing 
the advantages to be gained by such practice, both in saving the life 
of the child as well as securing the greater safety of the mother." 
It would be impossible to put the matter in a stronger or clearer 
light, and I feel confident that these views will be endorsed by all 
who have adopted the more modern practice. 

1 Fourth Clinical Report of the Rotunda Lying-in Hospital for the year ending 
1872. 



PROLONGED AND PRECIPITATE LABORS. 335 

Effect of Early Interference on the Infantile Mortality. — In the first 
edition of this work I used the statistics of Dr. Hamilton, of Falkirk, 
and other modern writers, as proving that a more frequent use of the 
forceps than has been customary, diminished in a remarkable degree 
the infantile mortality. Dr. Galabin 1 has recently published an ad- 
mirable paper on this subject, in which, by a careful criticism of 
these figures, he has, I think, proved that the conclusions drawn from 
them are open to doubt, and that the saving of infantile life follow- 
ing more frequent forceps delivery is by no means so great as I had 
supposed. This, however, does not in any way touch the main points 
at issue referred to in the preceding paragraph. 

Possible Dangers Attending the Use of the Forceps. — It is, of course, 
right that we should consider the opposite point of view, and reflect 
on the disadvantages which may attend the interference advocated. 
Here I should point out that I am now talking only of the use of the 
forceps in simple inertia, when the head is low in the pelvic cavity, 
and when all that is wanted is a slight vis d fronte to supplement 
the deficient vis a tergo. The use of the instrument when the head 
is arrested high in the pelvis, or in cases of deformity, or before the 
os uteri is completely expanded, is an entirely different and much 
more serious matter, and does not enter into the present discussion. 
The chief question to decide is if there be sufficient risk to the mother 
to counterbalance that of delay. It will, of course, be conceded by 
all, that the forceps in the hands of a coarse, bungling, and ignorant 
practitioner, who has not studied the proper mode of operating, may 
easily inflict serious damage. The possibility of inflicting injury in 
this way should act as a warning to every obstetrician to make him- 
self thoroughly acquainted with the proper mode of using the instru- 
ment, and to acquire the manual skill which practice and the study 
of the mechanism of delivery will alone give ; but it can hardly be 
used as an argument against its use. If that were admitted, surgical 
interference of any kind would be tabooed, since there is none that 
ignorance and incapacity might not render dangerous. 

Assuming, therefore, that the practitioner is able to apply the for- 
ceps skilfully, is there any inherent clanger in its use ? I think all 
who dispassionately consider the question must admit that, in the 
class of cases alluded to, the operation is so simple that its disad- 
vantages cannot for a moment be weighed against those attending 
protraction and its consequences. Against this conclusion statistics 
may possibly be quoted, such as those of Churchill, who estimated 
that 1 in 20 mothers delivered by forceps in British practice were 
lost. But the fallacy of such figures is apparent on the slightest 
consideration ; and by no one has this been more conclusively shown 
than by Drs. Hicks and Phillips in their paper on tables of mortality 
after obstetric operations, 2 where it is proved in the clearest manner 
that such results are due not to the treatment, but rather to the fact 
that the treatment was so long delayed. 

1 Obstetrical Journal, December, 1877. 

2 Obst. Trans, vol. xiii. 



336 LABOR. 

Impossibility of giving Definite Rules for use of Forceps. — It is 
quite impossible to lay clown any precise rule as to when the forceps 
should be used in uterine inertia. Each case must be treated on its 
own merits, and after a careful estimate of the effect of the pains. 
The rules generally taught were, that the head should be allowed to 
rest at or near the perineum for a number of hours, and that inter- 
ference was contra-indicated if the slightest progress were being 
made. It is needless to say that both of these rules are incompatible 
with the views I have been inculcating, and that any rule based upon 
the length of time the second stage of labor has lasted must neces- 
sarily be misleading. What has to be done, I conceive, is to watch 
the progress of the case anxiously after the second stage has fairly 
commenced, and to be guided by an estimate of the advance that is 
being made and the character of the pains, bearing in mind that the 
risk to the mother, and still more to the child, increases seriously 
with each hour that elapses. If we find the progress slow and un- 
satisfactory, the pains flagging and insufficient, and incapable of 
being intensified by the means indicated, then, provided the head be 
low in the pelvis, it is better to assist at once by the forceps, rather 
than to wait until we are driven to do so by the state of the pa- 
tient. 1 

1 It may, perhaps, be of interest in connection with this important topic in prac- 
tical midwifery, if I reprint a letter I published some years ago in the Medical Times 
and Gazette. An historical case, such as that of which it treats, will better illus- 
trate the evil effects that may follow unnecessary delay than any amount of argument. 
It seems to me impossible to read the details of the delivery it describes without 
being forcibly struck with the disastrous results which followed the practice adopted, 
which, however, was strictly in accordance with that which, up to a quite recent date, 
has been considered correct by the highest obstetric authorities. 

ON THE DEATH OF THE PRINCESS CHARLOTTE OF WALES. 

(To the Editor of the Medical Times and Gazette.) 

Sir: The letter of your correspondent, "An Old Accoucheur," regarding the 
death of the Princess Charlotte, raises a question of great interest — viz., whether 
the fatal result might have been averted under other treatment ? The history of the 
case is most instructive, and I think a careful consideration of it leaves little room to 
doubt that, though the management of the labor was quite in accordance with the 
teaching of the day, it was entirely opposed to that of modern obstetric science. 
The following account of the labor may interest your readers and will probably be 
new to most of them. It is contained in a letter from Dr. John Sims to the late Dr. 
Joseph Clarke, of Dublin: — 

London, November 15, 1S17. 
" My Dear Sir. — I do not wonder at your wishing to have a correct statement of 
the labor of her Royal Highness the Princess Charlotte, the fatal issue of which has 
involved the whole nation in distress. You must excuse my being very concise, as I 
have been and am very much hurried. I take the opportunity of writing this in a 
lying-in chamber. Her Royal Highness' s labor commenced by the discharge of the 
liquor amnii about seven o'clock on Monday evening, and the pains followed soon 
after. They continued through the night and a great part of the next day — sharp, 
soft, but very ineffectual. Towards the evening Sir Richard Croft began to suspect 
that labor might not terminate without artificial assistance, and a message was de- 
spatched for me. I arrived at two on Wednesday morning. The labor was now 
advancing more favorably, and both Dr. Baillie and myself concurred in the opinion 



PROLONGED AND PRECIPITATE LABORS. 337 

Precipitate Labor less common than Lingering. — Undue rapidity of 
labor is certainly more uncommon than its converse, but still it is by 

that it would not be advisable to inform her Royal Highness of my arrival. From 
this time to the end of her labor the progress was uniform, though very slow, the 
patient in good spirits, the pulse calm, and there never was room to entertain a ques- 
tion about the use of instruments. About six in the afternoon the discharge became 
of a green color, which led to a suspicion that the child might be dead ; still the 
giving assistance was quite out of the question, as the pains now became more 
effectual, and the labor proceeded regularly though slowly. The child was born 
without artificial assistance at nine o'clock in the evening. Attempts were made for 
a good while to reanimate it by inflating the lungs, friction, hot baths, etc., but with- 
out effect ; the heart could not be made to beat even once. Soon after delivery Sir 
Richard Croft discovered that the uterus was contracted in the middle in the hour- 
glass form, and as some hemorrhage commenced it was agreed that the placenta 
should be brought away by introducing the hand. This was done about half an hour 
after the delivery of the child with more ease and less loss of blood than usual. Her 
Royal Highness continued well for about two hours ; she then complained of being 
sick at stomach, and of noise in the ears, began to be talkative, and her pulse became 
frequent ; but I understand she was very quiet after this, and her pulse calm. About 
half-past twelve o'clock she complained of severe pain in her chest, became ex- 
tremely restless, with rapid, weak, and irregular pulse. At this time I saw her for 
the first time. It has been said that we had all gone to bed, but that is not a fact ; 
Croft did not leave her room, Baillie retired about eleven, and I went to my bed- 
chamber and laid down in my clothes at twelve. By dissection, some bloody fluid 
(two ounces) was found in the pericardium, supposed to be thrown out in articulo 
mortis. The brain and other organs all sound, except the right ovarium, which was 
distended into a cyst the size of a hen's egg. The hour-glass contraction of the 
uterus still visible, and a considerable quantity of blood in the cavity of the uterus — 
but those present dispute about the quantity, so much as from twelve ounces to a 
pound and a half — her uterus extending as high as her navel. The cause of her 
Royal Highness' s death is certainly somewhat obscure : the symptoms were such as 
attend death from hemorrhage, but the loss of blood did not seem to be sufficient to 
account for a fatal issue. It is possible that the effusion into the pericardium took 
place earlier than was supposed, and it does not seem to be quite certain that this 
might not be the cause. That I did not see her Royal Highness more early was 
awkward, and it would have been better that I had been introduced before the labor 
was expected ; and it should have been understood that when labor came on I should 
be sent to without waiting to know whether a consultation was necessary or not. I 
thought so at the time, but I could not propose such an arrangement to Croft. But 
this is entirely entre nous. I am glad to hear that your son is well, and, with all my 
family, wish to be remembered to him. We were happy to hear that he was agree- 
ably married. " I remain, my dear Doctor, 

' ' Ever yours most truly, 

"John Sims, M.D. 

"This letter is confidential, as perhaps I might be blamed for writing any particu- 
lars without the permission of Prince Leopold." 

What are the facts here shown ? Here was a delicate young woman prepared for 
the trial before her, as Baron Stockmar tells us, by "lowering the organic strength 
of the mother by bleeding, aperients, and low diet," who was allowed to go on in 
lingering feeble labor for no less than fifty-two hours after the escape of the liquor 
amnii ! Such was the groundless dread of instrumental interference then prevalent 
that, although the case dragged on its weary length with feeble ineffectual pains, 
every now and then increasing a little in intensity and then falling off again, it is 
stated "there never was room to entertain a question about the use of instruments ; " 
and even " when the discharge became of a green color . . . still the giving assist 
ance was quite out of the question!" Can any reasonable man doubt that if the 
forceps had been employed hours and hours before — say on Tuesday, when the pains 
fell off — the result would probably have been very different, and that the life of the 
child, destroyed by the enormously prolonged second stage, would have been saved ? 



338 LABOR. 

no means of unfrequent occurrence. Most obstetric works contain a 
formidable catalogue of evils that may attend it, such as rupture of 
the cervix, or even of the uterus itself, from the violence of the 
uterine action ; laceration of the perineum from the presenting part 
being driven through before dilatation has occurred ; fainting from 
the sudden emptying of the uterus ; hemorrhage from the same 
cause. With regard to the child it is held that the pressure to which 
it is subjected, and sudden expulsion while the mother is in the erect 
position, may prove injurious. Without denying that these results 
may possibly occur now and again, in the majority of cases over- 
rapid labor is not attended with any evil effects. 

Precipitate labor may generally be traced to one of two conditions, 
or to a combination of both ; excessive force and rapidity of the 
pains, or unusual laxity and want of resistance of the soft parts. 
The precise causes inducing these it is difficult to estimate. In some 
cases the former may depend on an undue amount of nervous ex- 
citability, and the latter on the constitutional state of the patient 
tending to relaxation of the tissues. 

Whatever the cause, the extreme rapidity of labor is occasionally 
remarkable, and one strong pain may be sufficient to effect the ex- 
pulsion of the child, with little or no preliminary warning. 1 I have 
known a child to be expelled into the pan of a water-closet, the only 
previous indication of commencing labor being a slight griping pain, 

It must be remembered that early on Tuesday morning delivery was expected, so 
that the head must then have been low in the pelvic (vide Stoekmar's "Memoirs," 
vol. i. p. 63). It would be difficult to find a case which more forcibly illustrates the 
danger of delay in the second stage of labor. Then what follows ? The uterus, 
exhausted by the lengthy efforts it should have been spared, fails to contract effect- 
ually ; nor do we hear of any attempts to produce contraction by pressure. The 
relaxed organ becomes full of clots, extending up to the umbilicus, and all the most 
characteristic symptoms of concealed post-partum hemorrhage develop themselves. 
She complained "of being sick at stomach, and of noise in her ears — began to be 
talkative, and her pulse became frequent." Before long other symptoms came on, 
graphically described by Baron Stockmar, and which seem to point to the formation 
of a clot in the heart and pulmonary arteries — a most likely occurrence after such a 
history. " Baillie sent me word that he wished me to see the Princess. I hesitated, 
but at last went Avith him. She was suffering from spasms of the chest and difficulty 
of breathing, in great pain, and very restless, and threw herself continually from one 
side of the bed to the other, speaking now to Baillie, now to Croft. Baillie said to 
her — ' Here comes an old friend of yours.' She held out her left hand to me 
hastily, and pressed mine warmly twice. I felt her pulse ; it was going very fast — 
the beats now strong, now feeble, now intermittent." 

Here was evidently something different from the exhaustion of hemorrhage ; and 
no one who has witnessed a case of pulmonary obstruction can fail to recognize in 
this account an accurate delineation of its dreadful symptoms. 

Surely this lamentable story can only lead to the conclusion that the unhappy and 
gifted Princess fell a victim to the dread of that bugbear, " meddlesome midwifery," 
which has so long retarded the progress of obstetrics, 

I am, etc., W. S. Playfair. 

Curzon-street, Mayfair, W., November 29, 1872. 

1 [In two cases seen by the editor, a spinal affection perverted, or diminished the 
natural feelings of the pelvic organs, and induced a belief that defecation was immi- 
nent. Where the dropped child is illegitimate and dead, it may bring the mother 
under suspicion of infanticide. — Ed.] 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 339 

which led the mother to fancy that an action of the bowels was about 
to take place. More often there is what may be described as a storm 
of uterine contractions, one pain following the other with great in- 
tensity, until the foetus is expelled. The natural effect of this is to 
produce a great amount of alarm or nervous excitement, which of 
itself forms one of the worst results of this class of labor. It is 
under such circumstances that temporary mania occurs, produced by 
the intensity of the suffering, under which the patient may commit 
acts her responsibility for which may fairly be open to question. 

Treatment. — Little can be done in treating undue rapidity of labor. 
We can, to some extent, modify the intensity of the pains by urging 
the patient to refrain from voluntary efforts, and to open the glottis 
by crying out, so that the chest may no longer be a fixed point for 
muscular action. Opiates have been advised to control uterine 
action, but it is needless to point out that, in most cases, there is no 
time for them to take effect. Chloroform will often be found most 
valuable, from the rapidity with which it can be exhibited ; and its 
power of diminishing uterine action, which forms one of its chief 
drawbacks in ordinary practice, will here prove of much service. 



CHAPTER X. 

LABOR OBSTRUCTED BY FAULTY CONDITION OF THE SOFT PARTS. 

Rigidity of the Cervix a frequent Cause of Protracted Labor. — One 
of the most frequent causes of delay in the first stage of labor is 
rigidity of the cervix uteri, which may depend on a variety of con- 
ditions. It is often produced by premature escape of the liquor 
amnii, in consequence of which the fluid wedge, which is nature's 
means of dilating the os, is destroyed and the hard presenting part 
is consequently brought to bear directly upon the tissues of the cer- 
vix, which are thus unduly irritated, and thrown into a state of 
spasmodic contraction. At other times it may be due to consti- 
tutional peculiarities, among which there is none so common as a 
highly nervous and emotional temperament, which renders the patient 
peculiarly sensitive to her sufferings, and interferes with the har- 
monious action of the uterine fibres. The pains, in such cases, cause 
intense agony, are short and cramp-like in character, but have little 
or no effect in producing dilatation ; the os often remaining for many 
hours without any appreciable alteration, its edges being thin and 
tightly stretched over the head. Less often, and this is generally 
met with in stout plethoric women, the edges of the os arc thick 
and tough. 



840 LABOR. 

Effects. — The effects of prolongation of labor from this cause will 
vary much under different circumstances. If the liquor amnii be 
prematurely evacuated, the presenting part presses directly upon the 
cervix, and the case is then practically the same as if the labor were 
in the second stage. Hence grave symptoms may soon develop them- 
selves, and early interference may be imperatively demanded. If the 
membranes be unruptured, delay will be of comparatively little 
moment, and considerable time may elapse without serious detriment 
to either the mother or child. 

Treatment. — The treatment will naturally vary much with the 
cause, and the state of the patient. In the majority of cases, especi- 
ally if the membranes be still intact, patience and time are sufficient 
to overcome the obstacle ; but it is often in the power of the ac- 
coucheur materially to aid dilatation by appropriate management. 
Sometimes nature overcomes the obstruction by lacerating the oppos- 
ing structures, and cases are on record in which even a complete 
ring of the cervix has been torn off, and come away before the head. 

Many remedies have been recommended for facilitating dilatation, 
some of which no doubt act beneficially. Amongst those most 
frequently resorted to was venesection, and with it was generally 
associated the administration of nauseating doses of tartar emetic. 
Both these acted by producing temporary depression, under which 
the resistance of the soft parts was lessened. They probably answered 
best in cases in which there was a rigid and tough cervix; and they 
might prove serviceable, even yet, in stout plethoric women of robust 
frame. Practically they are now seldom, if ever, employed, and 
other and less debilitating remedies are preferred. The agent, par 
excellence, which is most serviceable is chloral, which is of special 
value in the more common cases in which rigidity is associated with 
spasmodic contraction of the muscular fibres of the cervix. Two to 
three doses of 15 grains, repeated at intervals of twenty minutes, are 
often of almost magical efficacy, the pains becoming steady and 
regular, and the os gradually relaxing sufficiently to allow the passage 
of the head. Chloroform acts much in the same way, but on the 
whole less satisfactorily, its effects being often too great ; while the 
peculiar value of chloral is its influence in promoting relaxation of 
the tissues, without interfering with the strength of the pains. 

Local Means of Treatment. — Various local means of treatment may 
be also advantageously used. One is the warm bath, which is much 
used in France. It is of unquestionable value where there is much 
rigidity, and may be used either as an entire bath, or as a hip bath, in 
which the patient sits from twenty minutes to half an hour. The objec- 
tion is the fuss and excitement it causes, and, for this reason, it is an 
expedient seldom resorted to in this country. A similar effect is pro- 
duced, and much more easily, by a douche of tepid water upon the 
cervix. This can be very easily administered, the pipe of a Higgin- 
son's syringe being guided up to the cervix by the index finger of 
the right hand, and a stream of water projected against it for five 
or ten minutes. Smearing the os with extract of belladonna is 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 341 

advised by Continental authorities, but its effects are more than 
doubtful. 

Artificial dilatation of the cervix by the finger has often been re- 
commended, and has been the subject of much discussion, especially 
in the Edinburgh school, where it was formerly commonly employed. 
It is capable of being very useful, but it may also do much injury 
when roughly and injudiciously used. The class of cases in which 
it is most serviceable are those in which the liquor amnii has been 
long evacuated, and in which the head, covered by the tightly 
stretched cervix, has descended low into the pelvic cavity. Under 
these circumstances, if the finger be passed gently within the os 
during a pain, and its margin pressed upwards and over the head, 
as it were, while the contraction lasts, the progress of the case may be 
materially facilitated. This manoeuvre is somewhat similar to that 
which has been already spoken of, when the anterior lip of the cervix 
is caught between the head and the pubic bone, and, if properly per- 
formed, I believe it to be quite safe, and often of great value. It is 
not, however, well adapted for those cases in which the membranes are 
still intact, or in which the os remains undilated when the head is 
still high in the pelvis. "When there is much delay under these condi- 
tions, and interference of some kind seems called for, the dilatation 
may be much assisted by the use of caoutchouc dilators, described 
in the chapter on the induction of premature labor, which imitate 
nature's method of opening up the os, and also act as a direct stimu- 
lant to uterine contraction. But it should be remembered, that it is 
precisely in such cases that delay is least prejudicial. If, however, 
the os be excessively long in opening, its dilatation may be safely 
and efficiently promoted by passing within it, and distending with 
water, one of the smallest sized bags ; and, after this has been in 
position from ten to twenty minutes, it may be removed, and a larger 
one substituted. 

Rigidity depending upon Organic Causes. — Every now and again 
we meet with cases in which the obstacle depends upon organic 
changes in the cervix, the most common of which are cicatricial 
hardening from former lacerations ; hypertrophic elongation of the 
cervix from disease antecedent to pregnancy ; or even agglutination 
and closure of the os uteri. Cicatrices are generally the result of 
lacerations during former labors. They implicate a portion only of 
the cervix, which they render hard, rigid, and undilatable, while the 
remainder has its natural softness. They can readily be made out 
by the examining finger. A somewhat similar, but much more for- 
midable, obstruction is occasionally met with in cases of old standing 
hypertrophic elongation of the cervix, which is generally associated 
with prolapse. In most cases of this kind the cervix becomes soft- 
ened during pregnancy, so that dilatation occurs without any un- 
usual difficulty. But this does not always happen. A good ex- 
ample is related by Mr. Roper, in the seventh volume of the " Ob- 
stetrical Transactions," in which such a cervix formed an almost 
insuperable obstacle to the passage of the child. 

Carcinoma of the cervix uteri, which produces extensive thicken- 



342 LABOR. 

ing and induration of its tissues, and even advanced malignant dis- 
ease of the uterus, is no bar to conception. 

Occlusion of the Os. — Agglutination of the margins of the os uteri 
is occasionally met with, and must, of course, have occurred after 
conception. It is generally the result of some inflammatory affec- 
tion of the cervix during the early months of gestation, and I have 
known it recur in the same woman in two successive pregnancies. 
Usually it is not associated with any hardness or rigidity, but the 
entire cervix is stretched over the presenting part, and forms a 
smooth covering, in which the os may only exist as a small dimple, 
and maybe very difficult to detect at all. [Occlusion of the os uteri 
from inflammatory change, sometimes so alters the cervix, that no 
sign of the original opening can be discovered ; and in two such in- 
stances, the Cesarean operation has been performed in the United 
States, by which the women were saved. — Ed]. 

Their Treatment. — Any of these mechanical causes of rigidity may 
at first be treated in the same way as the more simple cases ; and 
with patience, the use of chloral and chloroform, and of the fluid 
dilators, sufficient expansion to permit the passage of the head will 
often take place. But if these methods produce no effect, and symp- 
toms of constitutional irritation are beginning to develop themselves, 
other, and more radical, means of overcoming the obstruction may 
be required. 

Incision of the Cervix. — Under such circumstances incision of the 
cervix may be not only justifiable but essential, and it frequently 
answers extremely well. On the Continent it is resorted to much 
more frequently and earlier than in this country, and with the most 
beneficial results. The operation offers no difficulties. The simplest 
way of performing it is to guard the greater portion of the blade of 
a straight blunt-pointed bistoury by wrapping lint or adhesive plas- 
ter round it, leaving about half an inch cutting edge towards its 
point. This is guided to the cervix, on the under surface of the 
index finger, and three or four notches are cut in the circumference 
of the os to about the depth of a quarter of an inch. Yeiy gener- 
ally, especially when the obstruction is only due to old cicatrices, the 
pains will now speedily effect complete expansion, which may 
be very advantageously aided by applying the hydrostatic dilators. 
When the obstruction is due to carcinomatous infiltration or inflam- 
matory thickening, the case is much more complicated, and will 
painfully tax the resources of the accoucheur. Still there can be no 
question that incisions should form a preliminary to any subsequent 
proceedings that may be necessary, as they are, at the worst, not 
likely to increase in the least the risks the patient has to run, and 
they may possibly avert more serious operations. In the case of 
malignant disease the risk of serious hemorrhage, from the great 
vascularity of the tissues, must not be forgotten, and, if necessary, 
means must be taken to check this by local styptics, such as per- 
chloride of iron. If incision fail, and the state of the patient de- 
mands speedy delivery, it may be necessary to reduce the bulk of 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 343 

the child by perforation, or, in the worst case of malignant infiltra- 
tion, even to resort to the Cesarean section. 

Application of the Forceps within the Cervix. — Before performing 
craniotomy, when the os is sufficiently open, a cautious application 
of the forceps is quite justifiable. Steady and careful downward 
traction, combined with digital expansion, has often enabled a head 
to pass with safety through an os that has resisted all other means 
of dilatation, and the destruction of the child has thus been avoided. 
If, indeed, the os appear to be dilatable, this procedure may advan- 
tageously be adopted before incision, and, as a matter of fact, it is 
commonly practised in the Eotunda Hospital. An operation involv- 
ing, beyond doubt, of itself some risk, and requiring considerable 
operative dexterity, would naturally not be lightly and inconsider- 
ately undertaken. But when it is remembered that the alternative 
is the destruction of the child, the risk of exhaustion, and at least 
as great mechanical injury to the mother, its difficulty need not stand 
in the way of its adoption. 

Treatment when Occlusion of the Os Exists. — When the os is appa- 
rently obliterated, incision is the only resource. Before resorting to 
it the patient should be placed under chloroform, and the entire lower 
segment of the uterus carefully explored. Possibly the aperture 
may be found high up, and out of reach of an ordinary examination, 
or we may detect a depression corresponding to its site. A small 
crucial incision may then be made at the site of the os, if this can 
be ascertained; if not, at the most prominent portion of the cervix. 
Very generally the pains will then suffice to complete expansion, 
which may be further aided by the fluid dilators. 

Bands and Cicatrices in the Vagina. — Extreme rigidity of the 
vagina, or bands and cicatrices in or across its walls, the result of 
congenital malformation, of injuries in former labors, or of antece- 
dent disease, occasionally obstruct the second stage. There is seldom 
any really formidable difficulty from this cause, since the obstruction 
almost always yields to the pressure of the presenting part. If there 
be any considerable extent of cicatrices in the vagina, artificial assist- 
ance may be required. If we should be awart; of their existence 
during pregnancy, and find them to be sufficiently dense and ex- 
tensive to be likely to interfere with delivery, an endeavor may be 
made to dilate them gradually by hydrostatic bags or bougies. If 
they be not detected until labor is in progress, we must be guided in 
our procedures by the pressure to which they are subjected. It may 
then be necessary to divide them with a knife, and to hasten the 
passage of the head by the forceps, so as to prevent contusion as 
much as possible. It is obviously impossible to lay down any posi- 
tive rules for such rare contingencies, the treatment suitable for which 
must necessarily vary much with the individual peculiarities of the 
case. 

Extreme rigidity of the perineum is often dependent upon cicatricial 
hardening from injury in previous labors. This may greatly inter- 
fere with its dilatation ; and if laceration seem inevitable, we may be 
quite justified in attempting to avert it by incision of the margins of 



344 LABOR. 

the perineum, on the principle of a clean cut being always preferable 
to a jagged tear. 

Labor Complicated with Tumor. — Occasionally we meet with very 
formidable obstacles from tumors connected with the maternal struc- 
tures. These are most commonly either fibroid or ovarian, although 
others may be met with, such as malignant growths from the pelvic 
bones, exostoses, etc. 

Fibroid Tumors of the Uterus. — Considering the frequency with 
which women suffer from fibroid tumors of the uterus, it is perhaps 
somewhat remarkable that they do not more often complicate de- 
livery. Probably women so affected are not apt to conceive. Occa- 
sionally, however, cases of this kind cause much anxiety. Of course, 
the cases are most grave in which the tumors are so situated as to 
encroach upon the cavity of the pelvis, and mechanicallv obstruct 
the passage of the child. Even those in which this does not occur 
are by no means free from danger, for interstitial and sub-peritoneal 
fibroids, situated in the upper parts of the uterus, and leaving the 
pelvic cavity quite unimplicated, may interfere with the action of 
the uterine fibres, prevent subsequent contraction, cause profuse post- 
partum hemorrhage, or even predispose to rupture of the uterine 
tissue. Hence, every case in which the existence of uterine fibroids 
has been ascertained must be anxiously watched. The risk of hemor- 
rhage is perhaps the greatest ; for, if the tumors be at all large, effi- 
cient contraction of the uterus after the birth of the child must be 
more or less interfered with. Fortunately it is not so common as 
might almost be expected. Out of 5 cases recorded in the " Obstet- 
rical Transactions," 2 of which were in my own practice, no hemor- 
rhage occurred ; nor does it seem to have happened in any of the 26 
cases collected by Magdelaine in his thesis on the subject. I recently 
saw an interesting example of this in a patient, whose case was 
looked forward to with much anxiety, in consequence of the exist- 
ence of several enormous fibroid masses projecting from the fundus 
and anterior surface of the body of the uterus, and whose labor was, 
nevertheless, typically normal in every way. Should hemorrhage 
occur after delivery, the injection of styptic solutions would probably 
be peculiarly valuable, since the ordinary means of promoting con- 
traction are likely to fail. 

It is when the fibroid growths implicate the lower uterine zone 
and the cervical region, that the greatest difficulties are likely to be 
met with. The practice then to be adopted must be regulated to a 
great extent by the nature of each individual case. If it be possible 
to push the tumor above the pelvic brim, out of the way of the pre- 
senting part, that, no doubt, is the best course to pursue, as not 
only clearing the passage in the most effectual way, but removing 
the tumor from the bruising to which it would otherwise be subjected 
when pressed between the head and the pelvic Avails, which seems to 
be one of the greatest dangers of this complication. This manoeuvre 
is sometimes possible in what seem to be the most unpromising 
circumstances. An interesting example is narrated by Mr. Spencer 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 



345 



Wells, 1 who, called to perform the Cesarean section, succeeded, 
although not without much difficulty, in pushing the obstructing 
mass above the brim, the child subsequently passing with ease. I 
have myself elsewhere recorded two similar cases 2 in which I was 
enabled to deliver the patient by pushing up the obstructing tumor, 
in both of which the Csesarean section would have been inevitable had 
the attempt at reposition failed. Therefore, before resorting to more 
serious operative procedures, a determined effort at pushing the 
tumor out of the way should be made, the patient being deeply 
chloroformed, and, if necessary, upward pressure being made by the 
closed fist passed into the vagina. 

Enucleation or Ablation. — Failing this, the possibility of enuclea- 
ting the tumor, or, if that be not possible, of removing it piecemeal 
with the e*craseur, should be considered. On account of the loose 
attachments of these growths, and the facility with which they can 
be removed in this way in the non- pregnant state, the expedient seems 
certainly well worthy of a trial, if their site and attachments render 
it at all feasible. Interesting examples of the successful performance 
of this operation are recorded by Danyau and Braxton Hicks. 
Should it be found impracticable, the case must be managed in refer- 
ence to the amount of obstruction ; and the forceps, craniotomy, or 
even the Caesarean section, may be necessary. 3 

Tumors of the Ovaries. — The next most common class of obstruct- 
ing tumors are those of the ovary (Fig. 120), and it is apparently 

Fig. 120. 




Labor Complicated by Ovarian Tumor. 

1 Obst. Trans., vol. ix. p. 73. 2 Obst. Trans., vol. xix. p. 101. 

[ 3 The great objection to the Caesarean operation, lies in the fact, that this class of 
L'ases is the most fatal of all in which this mode of delivery has been practised ; the 
i^reat danger arising from hemorrhage. — Ed.] 
23 



346 LABOR. 

not the largest of these which are most apt to descend into the pelvic 
cavity. When the tumor is of any considerable size, its bulk is 
such that it cannot be contained in the true pelvis, and it rises into 
the abdominal cavity with the uterus. Hence, the existence of the 
tumor that offers the most formidable obstacle to delivery is rarely 
suspected before labor sets in. 

In order to estimate the results of the various methods of treat- 
ment, I have tabulated 57 cases. 1 In 13 labor was terminated by 
the natural powers alone ; but of these 6 mothers, or nearly one-half, 
died. In favorable contrast with these we have the cases in which 
the size of the tumor was diminished by puncture. These are 9 in 
number, in all of which the mothers recovered ; 6 out of the 9 
children being saved. The reason of the great mortality in the 
former cases is apparently the braising to which the tumor, even 
when small enough to allow the child to be squeezed past it, is neces- 
sarily subjected. This is extremely apt to set up a fatal form of 
diffuse inflammation, the risk of which was long ago pointed out by 
Ashwell, 2 who draws a comparison between cases in which such 
tumors have been subjected to contusion and cases of strangulated 
hernia ; and the cause of death in both is doubtless very similar. 
This danger is avoided when the tumor is punctured, so as to become 
flattened between the head and the pelvic walls. On this account, I 
think, it should be laid down as a rule that puncture should be per- 
formed in all cases of ovarian tumor engaged in front of the pre- 
senting part, even when it is of so small a size as not to preclude the 
possibility of delivery by the natural powers. 

Treatment token Puncture Fails. — In 5 of the 57 cases it was found 
possible to return the tumor above the pelvic brim, and in these also 
the termination was very favorable, all the mothers recovering. 
Should puncture not succeed, and it may fail on account of the gelati- 
nous and semi- solid nature of the contents of the cyst, it may be 
possible to dispose of the tumor in this way, even when it seems to 
be firmly wedged down in front of the presenting part, and to be 
hopelessly fixed in its unfavorable position. 

Failing either of these resources, it may be necessary to resort to 
craniotomy, provided the size of the tumor precludes the possibility 
of delivery by forceps. 

The question of the effect on labor of ovarian tumor which does 
not obstruct the pelvic canal is one of some interest, but there are 
not a sufficient number of cases recorded to throw much light on it. 
I am disposed to think that labor generally goes on favorably. What 
delay there is depends on the inefficient action of the accessory mus- 
cles engaged in parturition, on account of the extreme distension of 
the abdomen. 

Polypus. — [Polypoid tumors sometimes act as serious obstacles to 
delivery. If long-pedicled they may pass out of the vagina in ad- 
vance of the foetus. If more firmly attached, they may be pushed 
up and secured by bringing down the child. They are sometimes 

1 Obst. Trans., vol. ix. 2 Guy's Hospital Reports, vol. ii. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 347 

detached and expelled during the labor, by the pressure of the head; 
or are removed by an ecraseur if recognized early. — Ed.] 

There are a few other conditions, connected with the maternal 
structures, which may impede delivery, but which are of compara- 
tively rare occurrence. 

Vaginal Cystocele. — Amongst them is vaginal cystocele, consisting 
of a prolapse of the distended bladder in front of the- presentation, 
where it forms a tense fluctuating pouch, which has been mistaken 
for an hydrocephalic head, or for the bag of membranes. This com- 
plication is only likely to arise when the bladder has been allowed to 
become unduly distended from want of attention to the voiding of 
urine during labor. The diagnosis should not offer any difficulty, 
for the finger will be able to pass behind, but not in front of, the 
swelling, and reach the presenting part ; while the pain and tenesmus 
will further put the practitioner on his guard. The treatment con- 
sists in emptying the bladder ; but there may be some difficulty in 
passing the catheter in consequence of the urethra being dragged 
out of its natural direction. A long elastic male catheter will 
almost always pass, if used with care and gentleness. Should it be 
found impossible to draw off the water, and this is said to have some- 
times happened, the tense pouch might be punctured without danger 
by the fine needle of an aspirator trocar, and its contents withdrawn. 
When once the viscus is emptied, it can easily be pushed above the 
presenting part in the intervals between the pains. 

Vesical Calculus. — In some few cases difficulties have arisen from 
the existence of a vesical calculus. Should this be pushed down in 
front of the head, it can readily be understood that the maternal 
structures would run the risk of being seriously bruised and injured. 
Should we make out the existence of a calculus — and, if the presence 
of one be suspected, the diagnosis could easily be made by means of 
a sound — an endeavor should be made to push it above the brim of 
the pelvis. If that be found to be impossible, no resource is left but 
its removal, either by crushing, or by rapid dilatation of the urethra, 
followed by extraction. Should we be aware of the existence of a 
calculus during pregnancy, its removal should certainly be under- 
taken before labor sets in. 

Hernial protrusion in Douglas's space may sometimes give rise to 
anxiety from the pressure and contusion to which it is necessarily 
subjected. An endeavor must be made to replace it, and to moderate 
the straining efforts of the patient ; and it may be even advisable to 
apply the forceps so as to relieve the mass from pressure as soon as 
possible. It is, however, of great rarity. Fordyce Barker, in an 
interesting paper on the subject, 1 records several examples, and states 
that he has met with no instance in which it has led to a fatal result 
either to mother or child, although it cannot but be considered a 
serious complication. 

Scybalous masses in the intestine may be so hard and impacted as 
to form an obstruction. The necessity of attending to the state of 

1 Amer. Journ. of Obstetrics, vol. ix. 



348 LABOR. 

the rectum has already been pointed ont. Should it be found im- 
possible to empty the bowel by large enemata, the mass must be 
mechanically broken down and removed by the scoop. 

(Edema of the Vulva. — Excessive oedematous infiltration of the 
vulva may sometimes cause obstruction, and require diminution in 
size, which can be easily effected by numerous small punctures. 

Hsematic effusions into the cellular tissue of the vulva or vagina 
form a grave complication of labor. Such blood swellings are most 
usually met with in one or both labia, or under the vaginal wall ; in 
the gravest forms, the blood may extend into the tissues for a con- 
siderable distance, as in the case recorded by Cazeaux, where it 
reached upwards as far as the umbilicus in front, and as far as the 
attachment of the diaphragm behind. 

Conditions favoring the Accident. — The conditions associated with 
pregnancy, the distension and engorgement to which the vessels are 
subjected, the interference with the return of the blood by the pres- 
sure of the head during labor, and the violent efforts of the patient, 
afforded a ready explanation of the reason, why a vessel may be 
predisposed to rupture and admit of the extravasation of blood. 

The accident is fortunately far from a common one, although a 
sufficient number of cases are recorded to make us familiar with its 
symptoms and risks. The dangers attending such effusions would 
seem to be great, if the statistics given by those who have written 
on the subject are to be trusted. Thus, out of 124 cases collected 
by various French authors, 44 proved fatal. Fordyce Barker points 
out that, since the nature and appropriate treatment of the accident- 
have been more thoroughly understood, the mortality has been much 
lessened ; for out of 15 cases reported by Scanzoni only 1 died, and 
out of 22 cases he had himself seen 2 died, and all these three deaths 
were from puerperal fever, and not the direct result of the accident. 1 

Situation of the Blood Effusions. — The blood may be effused into 
any part of the pelvic cellular tissue, or into the labia. The accident 
most often happens during labor when the head is Ioav down in the 
pelvis, not unfrequently just as it is about to escape from the vulva. 
Hence the extravasation is more often met with low down in the 
vagina, and more frequently in one of the labia than in any other 
situation. I have met with a case in which I had every reason to 
believe that an extravasation of blood had occurred within the 
tissues immediately surrounding the cervix. It is natural to suppose 
that a varicose condition of the veins about the vulva would pre- 
dispose to the accident, but in most of the recorded examples this 
is not stated to have been the case. Still, if varicose veins exist to 
any marked degree, some anxiety on this point cannot but be felt. 

Time of Occurrence. — The thrombus occasionally, though rarely, 
forms before delivery. Most commonly it first forms towards the end 
of labor, or after the birth of the child. In the latter case, it is pro- 
bable that the laceration in the vessels occurred before the birth of 

1 The Puerperal Diseases, p. 60. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 349 

the child, and that the pressure of the presenting part prevented the 
escape of any quantity of blood at the time of laceration. 

/Symptoms. — The symptoms are not by any means characteristic. 
Pain of a tearing character, occasionally very intense, and extending 
to the back and down the thighs, is very generally associated with the 
formation of the thrombus. If a careful physical examination be 
made, the nature of the case can readily be detected. "When the blood 
escapes into the labium, a firm, hard swelling is felt, which has even 
been mistaken for the foetal head. If the effusion implicate the in- 
ternal parts only, the diagnosis may not at first be so evident. But 
even then a little care should prevent any mistake, for the swelling may 
be felt in the vagina, and may even form an obstacle to the passage 
of the child. Cazeaux mentions cases in which it was so extensive 
as to compress the rectum and urethra, and even to prevent the exit 
of the lochia. In some cases the distension of the tissues is so great 
that they lacerate, and then hemorrhage, sometimes so profuse as 
directly to imperil the life of the patient, may occur. The bursting 
of the skin may take place sometime subsequent to the formation of 
the thrombus. Constitutional symptoms will be in proportion to the 
amount of blood lost, either by extravasation, or externally, after 
the rupture of the superficial tissues. Occasionally they are con- 
siderable, and are the same as those of hemorrhage from any cause. 

Termination. — The terminations of thrombus are either spontane- 
ous absorption, which may occur if the amount of blood extrava- 
sated be small ; or the tumor may burst, and then there is external 
hemorrhage ; or it may suppurate, the contained coagula being dis- 
charged from the cavity of the cyst ; or finally, sloughing of the 
superficial tissues has occurred. 

Treatment. — The treatment must naturally vary with the size of the 
thrombus, and the time at which it forms. If it be met with during 
labor, unless it be extremely small, it will be very apt to form an ob- 
struction to the passage of the child. Under such circumstances it is 
clearly advisable to terminate the labor as soon as possible, so as to 
remove the obstacle to the circulation in the vessels. For this purpose 
the forceps should be applied as soon as the head can be easily reached. 
If the tumor itself obstruct the passage of the head, or if it be of 
any considerable size, it will be necessary to incise it freely at its 
most prominent point and turn out the coagula, controlling the 
hemorrhage at once by filling the cavity with cotton wadding satu- 
rated in a solution of perchloride of iron, while, at the same time, 
digital compression with the tips of the fingers is kept up. By this 
means pressure is applied directly to the bleeding point, and the 
hemorrhage can be controlled without difficulty. This is all the 
more necessary if spontaneous rupture have taken place, for then the 
loss of blood is often profuse, and it is of the utmost importance to 
reach the site of the hemorrhage as nearly as possible. 

If the thrombus be not so large as to obstruct delivery, or if it be 
not detected until after the birth of the child, the question arises 
whether the case should not be left alone, in the hope that absorption 
may occur, as in most cases of pelvic hematocele. This expectant 



350 LABOR. 

treatment is advised by Cazeaux, and it seems to be the most ra- 
tional plan we can adopt. True it may take a longer time for the 
patient to convalesce completely than if the coagnla were removed 
at once, and the hemorrhage restrained by pressure on the bleeding 
point ; but this disadvantage is more than counterbalanced by the 
absence of risk from hemorrhage, and of septicaemia from the sup- 
puration that must necessarily follow. Softening and suppuration 
may, in many cases, occur in a few clays, necessitating operation, but 
the vessels will then be probably occluded, and the risk of hemor- 
rhage much lessened. Dr. Fordyce Barker, however, holds the 
opposite opinion and thinks that the proper plan is to open the 
thrombus early, controlling the hemorrhage in the manner already 
indicated, unless the thrombus is situated high in the vaginal canal. 

Bisk of Subsequent Septicaemia. — Whenever the cavity of a throm- 
bus has been opened, either by incision, or by spontaneous softening 
at some time subsequent to its formation, it must not be forgotten 
that there is considerable risk of septic absorption. To avoid this, 
care must be taken to use antiseptic dressings freely, such as the 
glycerine of carbolic acid applied directly to the part, and frequent 
vaginal injections of diluted Condy's fluid. Barker lays special 
stress on the importance of not removing prematurely the coagula 
formed by the styptic applications, for fear of secondary hemorrhage, 
but of allowing them to come away spontaneously. 

[Tetanoid Falciform Constriction of the Uterus. — Next to deformity 
of the pelvis, this form of obstacle is perhaps the most serious to be 
met with, of all those that interfere with the birth of a normally 
presenting foetus. To Dr. Alfred Hosmer, of Watertown, Massachu- 
setts, must be awarded the credit of having brought clearly before 
the medical world this rare form of dystocia ; in an article entitled, 
11 A peculiar condition of the cervix uteri, which is found in certain cases 
of dystocia, 11 presented before the Obstetrical Society of Boston, on 
February 9, 1878, and which will be found in the Boston Medical and 
Surgical Journal, March 21, 1878, p. 360. Attention having been 
called by him, to this serious, and sometimes fatal condition in par- 
turient women, several distant obstetricians of the United States 
have recognized in some of their former cases, the descriptions and 
explanations given, and have added materially to his statistical record 
by sending records of them to him. 

As it is often said, "there is nothing new under the sun," we were 
led to go back a little in history, after reading Dr. Hosmer's valuable 
papers, to see if it was possible that such a marked, although rare 
condition, could have been overlooked until this late date ; and in 
BlundelVs Obstetric Medicine, 1840, p. 166, Ave read the following: 
"In these turning cases you will sometimes meet with a third 
obstruction ; consisting in a circular contraction [italics his] of the 
middle of the womb; dividing it as it were into an upper and inferior 
chamber; part of the foetus lying in both. To judge from two or 
three cases of this kind which have fallen under my own notice, I 
should say that if you proceed with gentleness, resolutely, yet cau- 
tiously, and taking sufficient time, you will generally find that the 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 351 

hand may, on the whole, be passed through this sphincter with 
tolerable facility and safety ; but beware of force !" In another 
place he speaks of the obstacle as " the circular constriction of the 
uterus." But this description fails to set forth the condition, in the 
very serious and obstinate character in which it appears to have 
presented itself to Drs. Hosmer, E. E. Stone, of Newton, Mass., 
C. A. Thompson, of Jefferson City, Mo., and others. 

We will give Dr. Stone's case, to show how serious an obstacle 
this uterine constriction may prove to be. . . . Woman, 30, primi- 
para, short and stout; taken in labor September 4, 1876; pelvis 
somewhat contracted; in labor 70 hours, when Dr. Hosmer was 
called in consultation; os uteri well dilated; occiput of child pre- 
senting; labor had been active, but no advance of foetus; forceps 
applied and very strong traction used, but to no purpose; hand in- 
troduced for version by the feet, and constriction found, midway 
between os and fundus uteri, tightly grasping the foetal pelvis ; after 
much care and effort, one foot was brought down, and secured with 
a loop, but no force short of pulling off the extremity could bring 
down the breech ; head was then opened and emptied, and forceps 
again applied, but still no advance ; version was a second time tried, 
and by an unusual force, the other leg was brought down and a foetus 
of six or seven pounds removed. The woman was completely ex- 
hausted and died in 72 hours. 

In a second woman, the constriction was in the upper third in each 
of three labors, the band being large, firm, and with a sharp edge ; 
the first child weighed 9 J, and was delivered alive by version; second, 
10 J, also living, and by version; third, weighed 11 pounds; forceps 
failed; version performed, and head delivered by forceps; still-born; 
woman died on fourth day. (Cases of Dr. George J. Arnold, of Rox- 
bury, Mass., in 1872, 1874, and 1876.) 

In another case reported, the woman presented the same peculiarity 
in two labors ; and in the first, the constriction could be distinctly 
recognized through the abdominal wall, the upper chamber contain- 
ing the body and lower extremities, being twice the size of the lower; 
delivered by craniotomy and forceps. The second labor eighteen 
months later ended fatally ; the woman dying undelivered. (Cases 
of Dr. C. A. Thompson, of Missouri.) 

A seventh case also died undelivered, the uterus being ruptured 
in the effort to turn and bring down the feet. Of the seven instances 
given, all were head presentations; four were primiparse ; four died; 
and all the children were lost but two. The band felt to the hand 
of the operator more like a sharp metallic ring, than muscular tissue, 
and was not in the least influenced by anaesthesia. 

Dr. Hosmer believes that the stricture is at the internal os uteri, 
and that the cervix is dilated to form the lower chamber. He quotes 
in proof, a case of dilatation of the cervix examined by Ludwig 
Bandl, of Vienna, in which the os internum was as high as the um- 
bilicus, the cervix was as thin as paper, and covered more than half 
the foetus ; the forceps failed, craniotomy succeeded, and a child of 



352 LABOR. 

more than eight pounds delivered; woman discharged well in two 
weeks. 

According to the statements of Dr. Bandl, we see no similarity 
between his cases and those of Dr. Hosmer, except the fact that there 
was in some a constriction. Healthy primiparse in whom there are 
no evidences of a bladder-like cervix, are the subjects of the one 
condition ; and poor, ansemic, feeble multiparas, in whom there has 
been developed an atony of the cervix by repeated pregnancies, of 
the other. The latter is also associated with some slight pelvic de- 
formity, or a transverse position of the foetus, and is liable to result 
in a rupture of the thinned cervix. 

Dr. Bandl states, that in very thin subjects, the attenuated condition 
of the cervix may be felt through the abdominal walls. When labor 
has some time existed in such subjects, a constriction can be seen 
about a hand-breadth above the symphysis pubis. Palpation still 
more readily detects the constriction which, marks the dividing line 
between the neck and body of the uterus. A hand in the uterus 
detects a constriction high up, even surrounding and grasping some 
part of the child. 

This is certainly a different form of constriction from that given 
by Dr. Hosmer ; in whose cases attenuation of the cervix would have 
been a ready means of recognizing the form of dystocia, if it had 
existed. We do not see bow there could be a stricture at the internal 
os uteri, if in the upper third of the uterine sac, as in the three labors 
of Dr. Arnold's patient, without a very marked attenuation of the 
dilated neck of the womb. A few cases somewhat like those in the 
Vienna Hospital, have occurred in this city, and such was the dis- 
tinctness with which the foetus could be felt through the abdominal 
wall, that abdominal pregnancy was strongly suspected, until a normal 
labor revealed the presenting head. The wonder is that they escaped 
rupture. 

In a second paper by Dr. Hosmer, published in the journal before 
quoted, for May 30, 1878, p. 683, he enters into a long physiological 
explanation of what he conceives to be the cause and character of 
" ante- pa? -turn hour-glass contraction of the uterus" and recommends 
that the Csesarean operation should be resorted to as promising the 
most favorably for the mother. 

We have introduced this form of dystocia under a title, which 
conveys to the mind of the reader the peculiar nature of the obstruc- 
tion without any reference to its exact seat. Whether the constrict- 
ing ring is confined to the internal os, or may form at any point 
between it and the circular fibres of the cornua, we cannot answer 
positively although inclined to believe the latter ; what concerns us 
most is to know that there is such a form of dystocia; that we are 
liable to meet with it ; that it is dangerous to both foetus and mother ; 
how we are to recognize it; and what is best to be done. The most 
important step in treatment, is an early discovery of the existence 
of the stricture. Having the knowledge to make us cautious, we 
are to investigate the cause of delay by a manual exploration of the 
uterus, which has seldom been done, until very late in the labor. 



DYSTOCIA FROM F(ETUS. 



353 



We are then to turn the foetus, if not too difficult, by reason of the 
force required ; failing, in which, we may at once resort to gastro- 
hysterotomy if the woman is still in good condition of strength. 
We see no reason why the incision in the uterus should not be made 
in the usual way, as the general contraction of the organ will prob- 
ably obliterate the stricture. Laparo-elytrotomy is evidently not 
feasible, as the foetus cannot be drawn through the cervix. It is 
possible that morphia given to narcotism, or chloral in full doses, 
may cause the ring to relax; but we should have more hope in an 
early Caesarean operation, being satisfied that it is a much less danger- 
ous one in our own country than is generally believed. — Ed.] 



CHAPTEK XI. 



Fig. 121 



DIFFICULT LABOR DEPENDING ON SOME UNUSUAL CONDITION OF THE 

FOETUS. 

Plural Births. — The subject of multiple pregnancy in general 
having already beeu fully considered, we have now only to discuss its 
practical bearing as regards labor. Fortunately the existence of 
twins rarely gives rise to any serious 
difficulty. In the large proportion of 
cases the presence of a second foetus 
is not suspected until the birth of 
the first, when the nature of the case 
is at once apparent from the fact of 
the uterus remaining as large, or nearly 
as large as it was before. 

There may possibly be some delay 
in the birth of the first child, inasmuch 
as the extreme distension of the uterus 
may interfere with its thoroughly effi- 
cient action; while, in addition, the 
uterine pressure is not directly con- 
veyed to the ovum as in single births, 
but indirectly through the amniotic sac 
of the second child (Fig. 121). Such 
delay is especially apt to arise when 
the first child presents by the breech, 
for, even if the body be expelled spon- 
taneously, difficulty is likely to occur 
with the head, since the uterus does 
not contract upon it as is ordinarily the 
case. Hence the intervention of the accoucheur to save the life of 
the child, by the extraction of the head, will be almost a matter of 
necessity. 




Twin Pregnancy, Breech and Head 
presenting. 



354 LABOR. 

In the majority of cases, after the birth of the first child, there is a 
temporary lull in the pains, which soon recommence, generally in 
from ten to twenty minutes, and the second child is rapidly expelled ; 
for on account of the full dilatation of the soft parts, there is no ob- 
stacle to its delivery. Sometimes there is a considerable interval 
before the pains recur, and instances are recorded in which even 
several days have elapsed between the births of the two children. 

Treatment. — In most cases the management of twins does not differ 
from that of ordinary labor. As soon as we are certain of the ex- 
istence of a second foetus, we should inform the bystanders, but not 
necessarily the mother, to whom the news might prove an unpleasant 
and even dangerous shock. Then having taken care to tie the cord 
of the first child for fear of vascular communication between the 
placentas, our duty is to wait for a recurrence of the pains. If these 
come on rapidly, and the presentation of the second foetus be normal, 
its birth is managed in the usual way. 

Management when there is Delay after the Birth of the First Child. — 
If there be any unusual delay, we have to consider the proper course 
to pursue, and on this the opinions of authorities differ greatly. 
Some advise a delay of several hours, and even more, if pains do not 
recur spontaneously ; while others, Murphy for example, recommend 
that the second child should be delivered at once. Either extreme 
of practice is probably wrong, and the safest and best course is, 
doubtless, the medium one. The second point to bear in mind is, 
that, in multiple pregnancy, on account of the extreme distension of 
the uterus, there is a tendency to inertia, and consequently to post- 
partum hemorrhage ; and that, therefore, it is better that the birth 
of the second child should be delayed, even for a considerable time, 
rather than that the patient should run the risk attending an empty 
and uncontracted uterus. If, however, uterine action be present, 
there is an obvious advantage in the delivery of the second child 
before the dilatation of the passages passes off. 

Endeavors should be made to Excite Uterine Action. — The best plan 
would seem to be, if, after waiting a quarter of an hour, labor pains 
do not recur, to try and induce them by uterine friction and pressure, 
and by the administration of a dose of ergot, to which, as there can 
be no obstacle to the rapid birth of the second child, there can be 
now no objection. The membranes of the second child should always 
be ruptured at once, if easily within reach, as one of the speediest 
means of inducing contraction. If no progress be made, and speedy 
delivery be indicated — a necessity which may arise either from the 
exhausted state of the patient, the presence of hemorrhage, extremely 
feeble pulsations of the foetal heart (showing that the life of the 
secoDd child is endangered), or malpresentation of the second foetus — 
turning is probably the readiest and safest expedient. Under such 
circumstances the operation is performed with great ease, since the 
passages are amply dilated. After bringing down the feet, the birth 
of the body should be slowly effected, with the view of insuring as 
complete subsequent contraction as possible. If the head has de- 



DYSTOCIA FROM FOETUS. 



355 



scencled into the pelvis, of course turning is impossible, and the for- 
ceps must be applied. 

Difficulties arising from Locked Twins. — Occasionally very serious 
difficulties arise from parts of both foetuses presenting simultane- 
ously, and, either thus impeding the entrance of either child into the 
pelvis, or getting locked together, so as to render delivery impossible 
without artificial aid. Such difficulties are not apt to arise in the 
more ordinary cases, in which each child has its own bag of mem- 
branes, since then the foetuses are kept entirely separate ; but in those 
in which the twins are contained in a common amniotic cavity, or in 
which both sacs have burst simultaneously. They are very puzzling 
to the obstetrician, and it may be far from easy to discover the cause 
of the obstruction. Nor is it possible to lay down any positive rules 
for their management, which must be governed, to a considerable 
extent, by the circumstances of each individual case. 

Nature of these Cases. — Sometimes both heads present simultane- 
ously at the brim, and then neither can enter unless they be unusu- 
ally small or the pelvis very capacious, when both may descend ; 
or rather the first head may descend low into the pelvic cavity, and 
then the second head enters the brim, and gets jammed against the 

Fig. 122. 




Shows Head-locking, both Children presenting Head first. (After Barnes.) 

thorax of the first child (Fig. 122). Eeimann 1 relates a curious ex- 
ample of this, in which he delivered the first head with the forceps, 
but found the body would not follow, and, on examination, a second 
head was found in the pelvis. He then applied the forceps to the 



Arch. f. Gynak. 1871, 



356 LABOR. 

second head ; the body of the first child was then born, and after- 
wards that of the second. Such a mechanism must clearly have 
been impossible unless the pelvis had been extremely large. 

Both Heads Presenting Simultaneously. — Whenever both heads are 
felt at the brim, it will generally be found possible to get one out of 
the way by appropriate manipulation, one hand being passed into 
the vagina, the other aiding its action from without. Then the for- 
ceps may be applied to the other head, so as to engage it at once in 
the pelvic cavity. If both have actually passed into the pelvis, as in 
the case just alluded to, the difficulty will be much greater. It will 
generally be easier to push up the second head, while the lower is 
drawn out by the forceps, than to deliver the second, leaving the 
first in situ. 

Foot or Hand with Head. — In other cases a foot or a hand may de- 
scend along with the head, and even the four feet may present 
simultaneously. The rule in the former case, is to push the part 
descending with the head out of the way, and, in the latter, to dis- 
engage one child as soon as possible. Great care is necessary, or we 
might possibly bring down the limbs of separate children. 

Two Heads Interlocking. — The most common kind of difficulty is 
when the first child presents by the breech, and is delivered as far as 
the head, which is then found to be locked with the head of the 
second child, which has descended into the pelvic cavity (Fig. 123). 

Here it is clear that the obstruction must be very great, and, unless 
the children are extremely small, insuperable: The first endeavor 
should be to disentangle the heads ; this is sometimes feasible if the 
second be not deeply engaged in the pelvis, and the hand be passed 
up so as to push it out of the way. This will but rarely succeed ; 
then it may be possible to apply the forceps to the second head and 
drag it past the body of the first child, and this is the method re- 
commended by Eeimann, who has written an excellent paper on the 
subject. 1 Generally the sacrifice of one of the children is essential, 
and as the body of the first child must have been born for some time, 
it is probable that the pressure to which it has been subjected will 
have already imperilled, if it have not destroyed, its life, and there- 
fore the plan usually recommended is to decapitate. This can easily 
be done with scissors or a wire ecraseur, after which the second child 
is expelled without difficulty, leaving the head of the first in utero to 
be subsequently dealt with. 

Another mode of managing these cases is, to perforate the upper 
head, and draw it past the lower with the cephalotribe or craniotomy 
forceps. This plan has the disadvantage of probably sacrificing both 
children, since the other child can hardly survive the pressure and 
delay, whereas the former plan gives the second child a fair chance of 
being born alive. 

Double Monsters. — In connection with the subject of twin labor we 
may consider those rare cases in which the bodies of the foetuses are 
partially fused together. The mechanism and management of de- 

1 American Journal of Obstetrics, January, 1877. 



DYSTOCIA FROM FCETUS 



357 



livery in cases of double monstrosity have attracted comparatively 
little attention, no doubt because authors have considered them 
matters of curiosity merely, rather than of practical importance. 



Fig. 123. 




Shows Head-locking, first Child coming feet first ; Impaction of Heads from Wedging in Brim. 

(After Barnes.) 

D. Apex of wedge. E, c. Base of wedge which cannot enter hrim. A, B. Line of decapi- 
tation to decompose wedge, and enable head of second child to pass. 



The frequent occurrence of such monstrosities in our museums, 
and the numerous cases scattered through our periodical literature, 
are sufficient to show that they are not so very rare as we might be 
inclined to imagine ; and, as they are likely to give rise to formidable 
difficulties in delivery, it cannot be unimportant to have a clear idea 
of the usual course taken by nature in effecting such births, with 
a view of enabling us to assist in the most satisfactory manner should 
a similar case come under our observation. 

Unfortunately the authors, who have placed on record the birth of 



358 LABOR. 

double monsters, have generally occupied themselves more with a 
description of the structural peculiarities of the foetuses, than with 
the mechanism of their delivery ; so that, although the cases to be 
met with in medical literature are very numerous, comparatively few 
of them are of real value from an obstetric point of view. Still, I 
have been able to collect the details of a considerable number 1 in 
which the history of the labor is more or less accurately described ; 
and doubtless a more extensive research would increase the list. 

For obstetric purposes we may confine our attention to four prin- 
cipal varieties of double monstrosity, which are met with far more 
frequently than any others. These are : — 

A. Two nearly separate bodies united in front, to a varying ex- 
tent, by the thorax or abdomen. 

B. Two nearly separate bodies united back to back by the sacrum 
and lower part of the spinal column. 

C. Dicephalous monsters, the bodies being single below, but the 
heads separate. 

D. The bodies separate below, but the heads fixed are partially 
united. 

This classification by no means includes all the varieties of mon- 
sters that we may meet with. It does, however, include all that are 
likely to give rise to much difficulty in delivery ; and all the cases I 
have collected may be placed under one of these divisions. 

The first point that strikes us in looking over the history of these 
deliveries is the frequency with which they have been terminated 
by the natural powers alone, without any assistance on the part of 
the accoucheur. Thus, out of the 31 cases no less than 20 were de- 
livered naturally, and apparently without much trouble. Nothing 
can better show the wonderful resources of nature in overcoming 
difficulties of a very formidable kind. 

It is pretty generally assumed by authors that the children are 
necessarily premature, and, therefore of small size, and that delivery 
before the full term is rather the rule than the exception. Dugds 
states that the children are often dead, and that putrefaction has 
taken place, which facilitates their expulsion. Both these assump- 
tions seems to me to have been made without sufficient authority, and 
not to be borne out by the recorded facts. In only 1 of the 31 cases 
is it mentioned that the children were premature ; nor is there any 
insufficient reason that I can see why labor should commence before 
the full term of gestation. 

Class A. — By far the greatest number are included in the first 
class — that in which the bodies are nearly separate, but united by some 
part of the thorax or abdomen. This is the division which includes 
the celebrated Siamese Twins, an account of whose birth, I may ob- 
serve, I have not been able to discover. [The mother of these twins 
was a Chinese half-breed, short, and with a broad pelvis, and had 
borne several children previously. She stated on several occasions 
in conversation with parties in Siam, that the twins were born re- 

1 Obstet. Trans, vol. viii. 



DYSTOCIA FROM F(ETUS. 359 

versed, the feet of one being followed by the head of the other, and 
that they were very small and feeble at birth and for several months 
afterwards. The twins confirmed this statement by affirming that 
they could when little boys at play on the ground, turn themselves 
end for end upon the ensiform attachment, up to the age of ten or 
twelve, the attachment being then soft and pliable. — Ed.] Out of the 
31 cases, 19 come under this heading. The details of the labor are 
briefly as follows : — 1 died undelivered ; 8 were terminated by the 
natural powers, in 3 of which the feet, and in 3 the head presented ; 
in 2 the presentation is doubtful ; 6 were delivered by turning, or by 
traction on the lower extremities ; 4 were delivered instrumentally. 

Footling Presentation is the most Favorable. — The details of the 
cases in which the feet presented, or in which turning was performed, 
clearly show that footling presentation was by far the most favor- 
able, and it is fortunate the feet often present naturally. The infer- 
ence, of course, is, that version should be resorted to whenever any 
other presentation is met with in cases of double monstrosity of this 
type ; but, unfortunately, this rule could rarely be carried into exe- 
cution, since we possess no means of diagnosing the junction of the 
foetuses at a sufficiently early stage of labor to admit of turning being 
performed. It is only under exceptionably favorable circumstances 
that this can be done ; as, for example, in a case recorded by Molas, 1 
in which both heads presented, but neither would enter the brim of 
the pelvis. 

The Chief Difficulty is in the Delivery of the Heads. — The great diffi- 
culty must of course be in the delivery of the heads ; for in all the 
recorded cases, with one exception, the bodies have passed through 
the pelvis parallel to each other with comparative ease until the 
necks have appeared, and then, as a rule, they could be brought no 
farther. It is clear that the remainder of the foetuses could no longer 
pass simultaneously ; and, were direct traction continued, the heads 
would be inextricably fixed above the brim. In accordance with 
the direction of the pelvic axes the posterior head must first engage 
in the inlet ; and in order to effect this, it will be necessary to carry 
the bodies of the children well over the abdomen of the mother. 
This seems to be a point of primary importance. It would also be 
advisable to see that the bodies are made to pass through the pelvis 
with their backs in the oblique diameter. By this means more space 
is gained than if the backs were placed antero-posteriorly ; while, at 
the same time, there is less chance of the heads hitching against the 
promontory of the sacrum and symphysis pubis, which otherwise 
would be very apt to occur. 

Mode of Delivery when the Head Presents. — When the head pre- 
sents, and the labor is terminated by the natural powers, delivery 
seems to be accomplished in one of two ways. 

In the first and more common, the head and shoulders of one child 
are born, its breech and legs being subsequently pushed through the 
pelvis by a process similar to that of spontaneous evolution ; and, 

1 Mem. de l'Aeademie, vol. i. 



360 LABOR. 

afterwards, the second child probably passes footling without much 
difficulty. 

Barkow relates a case in which both heads were delivered by the 
forceps, the bodies subsequently passing simultaneously. Two 
similar instances are recorded in the third and sixth volumes of the 
" Obstetrical Transactions." When delivery takes place in this 
manner, the head of the second child must fit into the cavity formed 
by the neck of the first, and the pelvis must necessarily be suffi- 
ciently roomy to admit of the expulsion of the head of the second 
child, while its cavity is diminished in size by the presence of the 
neck and shoulders of the first. Either of these processes must ob- 
viously require exceptionally favorable conditions as regards the size 
of the child and the pelvis ; and the difficulty in the way of delivery 
must be much greater than when the lower extremities present. 
Therefore, I think the rule should be laid down that, when the nature 
of the case is made out (and for the purpose of accurate diagnosis a 
complete examination under anaesthesia should be practised), turning 
should be performed, and the feet brought down. 

Mutilation of the Foetuses. — In the event of its being found impos- 
sible to effect delivery after a considerable portion of the bodies is 
born, no resource remains but the mutilation of the body of one 
child, so as to admit of the passage of the other. This was found 
necessary in one case in which the children presented by the feet, 
and were born as far as the thorax, but could get no farther. The 
body of the anterior child was removed by a circular incision as far 
as it had been expelled, which allowed the remaining portion, con- 
sisting of the head and shoulders, to re-enter the uterus; after this 
the posterior child was easily extracted, and the mutilated foetus 
followed without difficulty. 

Class B. — Id class B, in which the children are united back to 
back, 3 cases are recorded, all of which were delivered by the natural 
powers. One of these is the case of Judith and Helene, the celebrated 
Hungarian twins, who lived to the age of twenty-one. 1 Helene was 
born as far as the umbilicus, and. after the lapse of three hours, her 
breech and legs descended. Judith was expelled immediately after- 
wards, her feet descending first. [The celebrated Carolina twins 
born July 11, 1851, and still living, were brought into the world by 
the same method, but the mother having a large pelvis, u had a brief 
and easy" delivery. The larger of the two girls also came first, as 
in the Szony case of 1701. These twins are now nearly six years 
older than the Hungarian sisters were at death. — Ed.] Exactly the 
same process occurred in a case described by M. Norman, the children 
being also born alive, and dying on the ninth day. 

Labor is easier than in Class A. — It is probable that labor is easier 
in this class of double monsters than in the former, because the 
children are so joined that there is no necessity for the bodies to be 
parallel to each other during birth when the head presents, and after 
the birth of the head and shoulders of the first child, its breech and 

1 Born, Oct. 26, 1701; died, Feb. 8, 1723. 



DYSTOCIA FROM FOETUS. 361 

lower extremities are evidently pushed down and expelled by a 
process of spontaneous evolution. If the feet originally presented, 
the mechanism of delivery and the rules to be followed would be the 
same as in class A ; but the difficulty would probably be greater, 
since the juncture is not so flexible, and a more complete parallelism 
of the bodies would be necessary during extraction. 

Glass G. — In class C, that of the dicephalous monster, I have found 
the description of the birth of 8 cases, 3 of which were terminated 
by the natural powers. In two of these, the process of evolution 
was the main agent in delivery; one head being born and becoming 
fixed under the arch of the pubis, the body being subsequently 
pushed past it, and the second head following without difficulty. 
This process failing, the proper course is to decapitate the first born 
head, and then bring down the feet of the child, when delivery can 
be accomplished with ease. This was the course adopted in 2 out 
of the 8 cases; and it may be done with the less hesitation, since, 
from their structural peculiarities, it is extremely improbable that 
monsters of this kind should survive. In the third case, terminated 
naturally, the heads were said to have been born simultaneously, but 
it seems probable that the one head lay in the hollow formed by the 
neck of the other, and so rapidly followed it. If the feet presented, 
the case may be managed in the same manner as in class A. 

Glass D. — Monstrosities of class D, in which the heads are united, 
the bodies being distinct, appear to be the most uncommon of all ; 
and I can find the description of delivery in only 2 cases. One of 
these gave rise to great difficulty; the labor in the other was easy. 
We should scarcely anticipate much difficulty in the birth of monsters 
of this type ; for, if the head presented and would not pass, we should 
naturally perform craniotomy; and if the bodies came first, the 
delivery of the monstrous head could readily be accomplished by 
perforation. 

Result to the Mothers. — The result to the mothers in all these cases 
seems to have been very favorable. There is only one in which the 
death of the mother is recorded; and although in many the result is 
not mentioned, we may fairly assume that recovery took place. 

Among difficulties in labor, some of the most important are due to 
morbid conditions of the foetus itself. 

Intra-uterine Hydrocephalus. — Of these the most common, as well 
as the most serious, is caused by intra-uterine hydrocephalus (giving 
rise to a collection of watery fluid within the cranium), by which the 
dimensions of the child's head are enormously increased, and the due 
relations between it and the pelvic cavity entirely destroyed (Fig. 
124). 

Its Danger both as regards the Mother and Child. — Fortunately, this 
disease is of comparatively rare occurrence, for it is one of great 
gravity both as regards the mother and child. As regards the 
mother, the serious character of the complication is proved by the 
statistics of Dr. Keiller, of Edinburgh, who found that, out of 74 
cases, no less than 16 were accompanied by rupture of the uterus. 
The reason of the danger to which the mother is subjected is obvious. 
24 



362 



LABOR 



In some few cases, indeed, the head is so compressible that, provided 
the amount of contained fluid be small, it may be sufficiently dimin- 
ished in size, by the moulding to which it is subjected, to admit of 
its being squeezed through the pelvis. In the majority of cases, 



Fig. 124. 




Labor Impeded by Hydrocephalus. 



however, the size of the head is too great for this to occur. The 
uterus therefore exhausts itself, and may even rupture, in the vain 
endeavor to overcome the obstacle; while the large and distended 
head presses firmly on the cervix, or on the pelvic tissues, if the os 
be dilated, and all the evil effects of prolonged compression are apt 
to follow. 

Its Diagnosis is not always easy. — The diagnosis of intra-uterine 
hydrocephalus is by no means so easy as the description in obstetric 
works would lead us to believe. It is true that the head is much 
larger and more rounded in its contour than the healthy foetal 
cranium, and also that the sutures and fontanelles are more wide, 
and admit occasionally of fluctuation being perceived through them. 
Still it is to be remembered that the head is always arrested above 
the brim, where it is consequently high up and difficult to reach, and 
where these peculiarities are made out with much difficulty. As a 
matter of fact, the true nature of the case is comparatively rarely 
discovered before delivery ; thus Chaussier 1 found that in more than 
one-half of the cases he collected an erroneous diagnosis had been 
iinade. 

Method of Diagnosis. — Whenever we meet with a case in which 
>either the history of previous labor, or a careful examination, con- 
vinces us that there is no obstacle due to pelvic deformity, in which 



Gazette Medicale, 1864. 



DYSTOCIA FROM F(ETUS. 363 

the pains are strong and forcing, but in which the head persistently 
refuses to engage in the brim, we may fairly surmise the existence 
of hydrocephalus. Nothing, however, short of a careful examination 
under anaesthesia, the whole hand being passed into the vagina so as 
to explore the presenting part thoroughly, will enable us to be quite 
sure of the existence of this complication. Under these circum- 
stances such a complete examination is not only justified but impera- 
tive ; and, when it has been made, the difficulties of diagnosis are 
lessened, for then we may readily make out the large round mass, 
softer and more compressible than the healthy head, the widely sepa- 
rated sutures, and the fluctuating fontanelles. 

Pelvic Presentations are frequently met vjith. — In a considerable 
proportion of cases — as many, it is said, as 1 out of 5 — the foetus 
presents by the breech. The diagnosis is then still more difficult ; 
for the labor progresses easily until the shoulders are born, when the 
head is completely arrested, and refuses to pass with any amount of 
traction that is brought to bear on it. Even the most careful exami- 
nation may not now enable us to make out the cause of the delay, 
for the finger will impinge on the comparatively firm base of the 
skull, and may be unable to reach the distended portion of the 
cranium. At this time abdominal palpation might throw some light 
on the case, for the uterus being tightly contracted round the head, 
we might be able to make out its unusual dimensions. The wasted 
and shrivelled appearance of the child's body, which so often accom- 
panies hydrocephalus, would also arouse suspicion as to the cause of 
delay. On the whole such cases may be fairly assumed to be less 
dangerous to the mother than when the head presents ; for, in the 
latter, the soft parts are apt to be subjected to prolonged pressure 
and contusion ; while in the former, delay does not commence till 
after the shoulders are born, and then the character of the obstacle 
would be sooner discovered, and appropriate means earlier taken to 
overcome it. 

Treatment. — 'The treatment is simple, and consists in tapping the 
head, so as to allow the cranial bones to collapse. There is the less 
objection to this course, since the disease almost necessarily precludes 
the hope of the child's surviving. The aspirator would draw off the 
fluid effectually, and would at least give the child a chance of life ; 
and, under certain circumstances, the birth of a child, who lives for 
a short time only, may be of extreme legal importance. More gene- 
rally the perforator will be used, and as soon as it has penetrated, a 
gush of fluid will at once verify the diagnosis. Schroeder recom- 
mends that, after perforation, turning should be performed, on account 
of the difficulty with which the flaccid head is propelled through the 
pelvis. This seems a very unnecessary complication of an already 
sufficiently troublesome case. As a rule, when once the fluid has 
been evacuated, the pains being strong, as they generally are, no 
delay need be apprehended. Should the head not come down, the 
cephalotribe may be applied, which takes a firmer grasp than the 
forceps, and enables the head to be crushed to a very small size and 
readily extracted. 



364 LABOR. 

Treatment when the Breech Presents. — When the breech presents, 
the head mnst be perforated through the occipital bone, and gene- 
rally this may be accomplished behind the ear without much diffi- 
culty. It has been said that opening of the vertebral canal might 
allow the intra- cranial fluid to escape, but I am not aware that the 
suggestion has ever been carried into practice. 

Other forms of dropsical effusion may give rise to some difficulty, 
but by no means so serious. In a few rare cases the thorax has 
been so distended with fluid as to obstruct the passage of the child. 
Ascites is somewhat more common; and, occasionally, the child's 
bladder is so distended with urine as to prevent the birth of the 
body. The existence of any of these conditions is easily ascertained ; 
for the head or breech, whichever happens to present, is delivered 
without difficulty, and then the rest of the body is arrested. This 
will naturally cause the practitioner to make a careful exploration, 
when the cause of the delay will be detected. 

The treatment consists in the evacuation of the fluid by puncture. 
In the case of ascites, this should always be done, if possible, by a 
fine trocar or aspirator, so as not to injure the child. This is all the 
more important since it is impossible to distinguish a distended 
bladder from ascites, and an opening of any size into that viscus 
might prove fatal, whereas aspiration would do little or no harm, 
and would prove quite as efficacious. 

Foetal Tumors Obstructing Delivery. — Certain foetal tumors may 
occasion dystocia, such as malignant growths, or tumors of the 
kidney, liver, or spleen. Cases of this kind are recorded in most 
obstetric works. Hydro-encephacele, or hydro-rachitis, depending 
on defective formation of the cranial or spinal bones, with the for- 
mation of a large protruding bag of fluid, is not very rare. The 
diagnosis of all such cases is somewhat obscure, nor is it possible to 
lay down any definite rules for their management, which must vary 
according to the particular exigencies. The tumors are rarely of 
sufficient size to prove formidable obstacles to delivery, and many of 
them are very compressible. This is especially the case with spina 
bifida and similar cystic growths. Puncture, and in the more solid 
growths of the abdomen or thorax, evisceration, may be required. 

Other Congenital Deformities. — Other deformities, such as the anen- 
cephalous foetus, or defective development of the thorax or abdominal 
parietes with protrusion of the viscera, are not likely to cause any 
difficulty; but they may much embarrass the diagnosis by the strange 
and unusual presentation that is felt. If, in any case of doubt, a full 
and careful examination be undertaken, introducing; the whole hand 
if necessary, no serious mistake is likely to be made. 

Dystocia from Excessive Development of the Foetus. — In addition to 
dystocia from morbid conditions of the foetus, difficulties may arise 
from its undue development, and especially from excessive size and 
advanced ossification of the skull. This last is especially likely to 
cause delay. Even the slight difference in size between the male 
and female head was found by Simpson to have an appreciable effect 
in increasing the difficulty of labor, when the statistics of a large 



DYSTOCIA FROM FCETUS. 365 

number of cases were taken into account; for he proved beyond 
doubt that the difficulties and casualties of labor occurred in de- 
cidedly larger proportion in male than in female births. Other cir- 
cumstances, besides sex, have an important effect on the size of the 
child. Thus Duncan and Hecker have shown that it increases in 
proportion to the age of the mother and the frequency of the labors, 
while the size of the parents has no doubt also an important bearing 
on the subject. 

Although these influences modify the results of labor en masse, 
they have little or no practical bearing on any particular case, since 
it is impossible to estimate either the size of the head, or the degree 
of its ossification, until labor is advanced. 

Its Treatment. — When labor is retarded by undue ossification or 
large size of the head, the case must be treated on the same general 
principles which guide us when the want of proportion is caused by 
pelvic contraction. Hence, if delay arise, which the natural powers 
are insufficient to overcome, it will seldom happen that the dispro- 
portion is too great for the forceps to overcome. If we fail to de- 
liver by it, no resource is left but perforation. 

Large Size of the Body rarely causes Delay. — Large size of the 
body of the child is still more rarely a cause of difficulty, for, if the 
head be born, the compressible trunk will almost always follow. 
Still, a few authentic cases are on record, in which it was found im- 
possible to extract the foetus on account of the unusual bulk of its 
shoulders and thorax. Should the body remain firmly impacted 
after the birth of the head, it is easy to assist its delivery by traction 
on the axillse, by gently aiding the rotation of the shoulders into the 
antero- posterior diameter of the pelvic cavity, and, if necessary, by 
extracting the arms, so as to lessen the bulk of the part of the body 
contained in the pelvis. Hicks relates a case in which evisceration 
was required for no other apparent reason than the enormous size of 
the body. The necessity for any such extreme measure must, of 
course, be of the greatest possible rarity ; and it is quite exceptional 
for difficulty from this source to be beyond the powers of nature to 
overcome. 



366 LABOR. 



CHAPTER XII. 

DEFORMITIES OF THE PELVIS. 

Deformities of the pelvis form one of the most important sub- 
jects of obstetric study, for from them arise some of the gravest 
difficulties and dangers connected with parturition. A knowledge, 
therefore, of their causes and effects, and of the best mode of de- 
tecting them, either during or before labor, is of paramount necessity ; 
but the subject is far from easy, and it has been rendered more dim- 
cult than it need be, from over-anxiety on the part of obstetricians 
to force all varieties of pelvic deformities within the limits of their 
favorite classification. 

Difficulties of Classification. — Many attempts in this direction have 
been made, some of which are based on the causes on which the 
deformities depend, others on the particular kind of deformity pro- 
duced. The changes of form, however, are so various and irregular, 
and similar, or apparently similar, causes so constantly produce dif- 
ferent effects, that all such endeavors have been more or less unsuc- 
cessful. For example, we find that rickets (of all causes of pelvic 
deformity the most important) generally produces a narrowing of 
the conjugate diameter of the brim; while the analogous disease, 
osteo-malacia, occurring in adult life, generally produces contraction 
of the transverse diameter, with approximation of the pubic bones, 
and relative or actual elongation of the conjugate diameter. We 
might, therefore, be tempted to classify the results of these two 
diseases under separate heads, did we not find that, when rickets 
affects children who are running about, and subject to mechanical 
influences similar to those acting upon patients suffering from osteo- 
malacia, a form of pelvis is produced hardly distinguishable from that 
met with in the latter disease. 

Most Simple Classification. — On the whole, therefore, the most 
simple, as well as the most scientific, classification is that which takes 
as its basis the particular seat and nature of the deformity. Let us 
first glance at the most common causes. 

Causes of Pelvic Deformity. — The key to the particular shape as- 
sumed by a deformed pelvis will be found in a knowledge of the cir- 
cumstances which lead to its regular development and normal shape 
in a state of health. The changes produced may, almost invariably, 
be traced to the action of the same causes which produce a normal 
pelvis, but which, under certain diseased conditions of the bones or 
articulations, induce a more or less serious alteration inform. These 
have been already described in discussing the normal anatomy of the 
pelvis, and it will be remembered that they are chiefly the weight of 
the body, transmitted to the iliac bones through the sacro-iliac joints, 



DEFORMITIES OF THE PELVIS. 867 

and counter-pressure on these, acting through the acetabula. Some- 
times they act in excess on bones which are healthy, but possibly 
smaller than usual, and the result may be the formation of certain 
abnormalities in the size of the various pelvic diameters. At other 
times they operate on bones which are softened and altered in texture 
by disease, and which, therefore, yield to the pressure far more than 
healthy bones. 

The two diseases which chiefly operate in causing deformity are 
rickets and osteo-malacia. Into the essential nature and symptoma- 
tology of these complaints it would be out of place to enter here ; it 
may suffice to remind the reader that they are believed to be patho- 
logically similar diseases, with the important practical distinction 
that the former occurs in early life before the bones are completely 
ossified, and that the latter is a disease of adults producing softening 
in bones that have been hardened and developed. This difference 
affords a ready explanation of the generally resulting A^arieties of 
pelvic deformity. 

Effects of Rickets. — Rickets commences very early in life, some- 
times, it is believed, even in utero. It rarely produces softening of 
the entire bones, and only in cases of very great severity of those 
parts of the bones that have been already ossified. The effects of the 
disease are principally apparent in the cartilaginous portions of the 
bones, in which osseous deposit has not yet taken place. The bones, 
therefore, are not subject to uniform change, and this fact has an 
important influence in determining their shape. Rickety children 
also have imperfect muscular development ; they do not run about 
in the same way as other children, they are often continuously in the 
recumbent or sitting postures, and thus the weight of the trunk is 
brought to bear, more than in a state of health, on the softened bones. 
For the same reason counter-pressure through the acetabula is absent 
or comparatively slight. When, however, the disease occurs for the 
first time in children who are able to run about, the latter comes into 
operation, and modifies the amount and nature of the deformity. It 
is to be observed that in rickety children the bones are not only 
altered in form from pressure, but are also imperfectly developed, 
and this materially modifies the deformity. When ossific matter is 
deposited, the bones become hard and cease to bend under external 
influences, and retain forever the altered shape they have assumed. 

Effects of Osteo-malacia. — In osteo-malacia, on the contrary, the 
already hardened bones become softened uniformly through all their 
textures, and thus the changes which are impressed upon them are 
much more regular, and more easily predicated. It is, however, an 
infinitely less common cause of pelvic deformity than rickets, as is 
evidenced by the fact that in the Paris Maternity in a period of sixteen 
years, 402 cases of deformity due to rickets occurred to 1 due to 
osteo-malacia. 1 

Their varying Frequency. — The frequency of both diseases varies 
greatly in different countries, and under different circumstances. 

1 Stanesco, Recherches Cliniques sur les R6tr6cissements du Bassin. 



368 LABOR. 

Eickets is much more common amongst the poor of large cities, 
whose children are ill-fed, badly clothed, kept in a vitiated atmo- 
sphere, and subjected to unfavorable hygienic conditions. Deformi- 
ties are, therefore, more common in them than in the more healthy 
children of the upper classes, or of the rural population. 1 The higher 
degrees of deformity, necessitating the Cesarean section, or crani- 
otomy, are in this country of extreme rarity ; while, in certain districts 
on the Continent, they seem to be so frequent that these ultimate 
resources of the obstetric art have to be constantly employed. 

Effects of Ossification of Pelvic Articulations. — In another class of 
cases the ordinary shape is modified by weight and counter-pressure 
operating on a pelvis in which one or more of the articulations is 
ossified. In this way we have produced the obliquely ovate pelvis of 
Naegele, or the still more uncommon transversely contracted pelvis of 
Eobert. 

Other Causes of Pelvic Deformity. — A certain number of deformed 
pelves cannot be referred to a modification of the ordinary develop- 
mental changes of the bones. Amongst these are the deformities 
resulting from spondylolithesis, or downward dislocation of the lower 
lumbar vertebras ; from displacements of the sacrum, produced by 
curvatures of the spinal column ; or from diseases of the pelvic bones 
themselves, such as tumors, malignant growths, and the like. 

Equally Enlarged Pelvis. — The first class of deformed pelves to be 
considered is that in which the diameters are altered from the usual 
standard, without any definite distortion of the bones ; and such are 
often mere congenital variations in size, for which no definite expla- 
nation can be given. Of this class is the pelvis which is equally 
enlarged in all its diameters {pelvis sequabiliter justo major), which is 
of no obstetric consequence, except insomuch as it may lead to pre- 
cipitate labor, and is not likely to be diagnosed during life. 

Equally Contracted Pelvis. — The corresponding diminution of all 
the pelvic diameters (pelvis sequabiliter justo minor) may be met with 
in women who are apparently well formed in every respect, and 
whose external conformation and previous history give no indica- 
tion of the abnormality. Sometimes the diminution amounts to 
half an inch or more, and it can readily be understood that such a 
lessening in the capacity of the pelvis would give rise to serious 
difficulty in labor. Thus, in 3 cases recorded by Naegele a fatal re- 
sult followed ; in 2 after difficult instrumental delivery, and in the 
third after rupture of the uterus. The equally lessened pelvis, how- 
ever, is of great rarity. An unusually small pelvis may be met with 
in connection with general small size, as in dwarfs. It does not 
necessarily follow, because a woman is a dwarf, that the pelvis is too 
small for parturition. On the contrary, many such women have 
borne children without difficulty. 

The Undeveloped Pelvis. — In some cases a pelvis retains its in- 
fantile characteristics after puberty (Fig. 125). The normal develop- 

1 [These appear to be more common among the blacks of Alabama and Louisiana, 
than any other part of our population ; and in these States the Ca?sarean operation 
has been the most frequently performed of any in the Union. — Ed.] 



DEFORMITIES OF THE PELVIS. 369 

merit of trie pelvis has been interfered with, possibly from premature 
ossification of the different portions of the innominate bones, or from 
arrest of their growth by a weakly or rachitic constitution. The 
measurements of these pelves are not always below the normal 
standard, they may continue to grow, although they have not de- 
veloped. The proportionate measurements of the various diameters 

Fig. 125. 




Adult Pelvis Retaining its Infantile Type. 

will then be as in the infant ; and the antero-posterior diameter may 
be longer, or as long, as the transverse, the ischia comparatively 
near each other, and the pubic arch narrow. Such a form of pelvis 
will interfere with the mechanism of delivery, and unusual difficulty 
in labor will be experienced. Difficulties from a similar cause may 
be expected in very young girls. Here, however, there is reason to 
hope that, as age advances, the pelvis will develop, and subsequent 
labors be more easy. 

Masculine or Funnel-shaped Pelvis. — The masculine, or funnel- 
shaped pelvis owes its name to its approximation to the type of the 
male pelvis. The bones are thicker and stouter than usual, the con- 
jugate diameter of the brim longer, and the whole cavity rendered 
deeper and narrower at its lower part by the nearness of the ischial 
tuberosities. It is generally met with in strong muscular women 
following laborious occupations, and Dr. Barnes, from his experience 
in the Eoyal Maternity Charity, says that it chiefly occurs in weavers 
in the neighborhood of Bethnal Green, who spend most of their 
time in the sitting posture. " The cause of this form of pelvis seems 
to be an advanced condition of ossification in a pelvis which would 
otherwise have been infantile, brought about by the development 
of unusual muscularity, corresponding to the laborious employment 
of the individual." The difficulties in labor will naturally be met 
with towards the outlet, where the funnel shape of the cavity is most 
apparent. 



370 LABOR. 

Contraction of Conjugate Diameter of Brim. — Diminution of the 
antero-posterior diameter is most frequently limited to the brim, and 
is by far the most common variety of pelvic deformity. In its 
slighter degrees it is not necessarily dependent on rickets, although 
when more marked it almost invariably is so. When unconnected 
with rickets, it probably can be traced to some injurious influence 
before the bones have ossified, such as increased pressure of the trunk 
from carrying weights in early childhood, and the like. By this 
means the sacrum is unduly depressed, and projects forwards, so as 
to slightly narrow the conjugate diameter. 

Mode of production in Rickets. — When caused by rickets the amount 
of the contraction varies greatly, sometimes being very slight, some- 
times sufficient to prevent the passage of the child altogether, and 
necessitate craniotomy of the Cesarean section. The sacrum, softened 
by the disease, is pressed vertically downwards by the weight of the 
body, its descent being partially resisted by the already ossified por- 
tions of the bone, so that the result is a downward and forward 
movement of the promontory. The upper portion of the sacral con- 
cavity is thus directed more backwards ; but, as the apex of the 
bone is drawn forwards by the attachment of the perineal muscles 
to the coccyx, and by the sacro-ischiatic ligaments, a sharp curve of 
its lower part in a forward direction is established. 

Occasional Increase of Transverse Diameter. — The depression of the 
sacral promontory would tend to produce strong traction, through 
the sacro-iliac ligaments, on the posterior ends of the sacro-cotyloid 
beams, and thus induce expansion of the iliac bones, and consequent 
increase of the transverse diameter of the brim. So an unusual 
length of the transverse diameter is very often described as accom- 
panying this deformity, but probably it is not so often apparent as 
might otherwise be expected, on account of the imperfect develop- 
ment of the bones generally accompanying rickets ; and Barnes 1 says 
that in the parts of London where deformities are most rife, any 
enlargement of the transverse diameter is -exceedingly rare. Fre- 
quently the sacrum is not only depressed, but displaced more or less 
to one side, most generally to the left, thus interfering with the 
regular shape of the deformed brim. This is often the result of a 
lateral flexion of the spinal column, depending on the rachitic dia- 
thesis. 

Cavity of Pelvis is generally not Affected. — In most cases of this 
kind the cavity of the pelvis is not diminished in size, and is often 
even more than usually wide. The constant pressure on the ischia, 
which the sitting posture of the child entails, tends to force them 
apart, and also to widen the pubic arch. Considerable advantage 
results from this in cases in which we have to perform obstetric ope- 
rations, as it gives plenty of room for manipulation. 

Figure-of-eight Deformity. — In a few exceptional cases the narrow- 
ing of the conjugate diameter is increased by a backward depression 
of the symphysis pubis, which gives the pelvic brim a sort of figure- 

1 Lectures on Obst. Operations, p. 280 



DEFORMITIES OF THE PELVIS. 



371 



of-eight shape (Fig. 126). The most reasonable explanation of this 
peculiarity seems to be, that it is the result of the muscular contrac- 
tion of the recti muscles, at their point of attachment, when the 
centre of gravity of the body is thrown backwards, on account of 



Fig. 126. 




Rickety Pelvis, with backward depression of the Symphysis Pubis. 

the projection of the sacral promontory. Sometimes also the antero- 
posterior diameter of the cavity is unusually lessened by the disap- 
pearance of the vertical curvature of the sacrum, which, instead of 
forming a distinct cavity, is nearly flat (Fig. 127). 

Fig. 127. 





Flatness of Sacrum with Narrowing of 
Pelvic Cavity. 



Pelvis Deformed by Spondylolithe-is. 
(After Kilian.) 



Spondylolithesis. — In a few rare cases, to which attention was first 
called in 1853 by Kilian of Bonn, a very formidable narrowing of 
the conjugate diameter of the pelvic brim is produced by a down- 
ward displacement of the fourth and fifth lumbar vertebraB, which 
become dislocated forward, or if not actually dislocated, at least 
separated from their several articulations to a sufficient extent to 
encroach very seriously on the dimensions of the pelvic inlet. This 
condition is known as spondylolithesis, (Fig. 128.) 



372 LABOR. 

The effect of this is sufficiently obvious, for the projection of the 
lumbar vertebrae prevents the passage of the child. To such an extent 
is obstruction thus produced, that, in the majority of the recorded 
cases, the Cesarean section was necessary. The true conjugate diam- 
eter, that between the promontory of the sacrum and the symphysis 
pubis, is increased rather than diminished ; but, for all practical pur- 
poses, the condition is similar to extreme narrowing of the conjugate 
from rickets, for the bodies of the displaced vertebras project into 
and obstruct the pelvic brim. 

The cause of this deformity seems to be different in different cases. 
In some it seems to have been congenital, and in others to have de- 
pended on some antecedent disease of the bones, such as tuberculosis 
or scrofula, producing inflammation and softening of the connection 
between the last lumbar vertebra and the sacrum, thus permitting 
downward displacement of the bones. Lambl believed that it gene- 
rally followed spina bifida, which had become partially cured, but 
which had produced deformity of the vertebrae, and favored their 
dislocation. Brodhurst, 1 on the other hand, thinks that it most prob- 
ably depends on rachitic inflammation and softening of the osseous 
and ligamentous structures, and that it is not a dislocation in the 
strict sense of the word. 

Narrowing of the Oblique Diameter. — [This disease is so rare in the 
United States, that it is not recorded in a single instance, as a cause 
for gastro-hysterotomy. — Ed.] The most marked examples of nar- 
rowing of both oblique diameters depend on osteo-malacia. In this 
disease, as has already been remarked, the bones are uniformly soft- 
ened; and the alterations in form are further influenced by the fact 
that the disease commences after union of the separate portions of 
the os innominatum has been completely effected. The amount of 
deformity in the worst cases is very great, and frequently renders 
delivery impossible without the Caesarean section. Sometimes the 
softening of the bones proves of service in delivery, by admitting of 
the dilatation of the contracted pelvic diameter by the pressure of the 
presenting part, or even by the hand. Some curious cases are on 
record in which the deformity was so great as to apparently require 
the Caesarean section, but in which the softened bones eventually 
yielded sufficiently to render this unnecessary. 

Mode of Production in Osteo-malacia. — The weight of the body de- 
presses the sacrum in a vertical direction, and at the same time 
compresses its component parts together, so as to approximate the 
base and apex of the bone, and narrow the conjugate diameter of 
the brim, by causing the promontory to encroach upon it. The most 
characteristic changes are produced by the pushing inwards of the 
walls of the pelvis at the cotyloid cavities, in consequence of pressure 
exerted at these points through the femurs. The effect of this is to 
diminish both oblique diameters, giving the brim somewhat the 
shape of a trefoil, or an ace of clubs. The sides of the pubis are at 
the same time approximated, and may become almost parallel, and 

1 Obst. Trans., vol. vi. p. 97. 



DEFORMITIES OF THE PELVIS 



373 



the true conjugate may be even lengthened (Fig. 129). The tuberosities 
of the ischia are also compressed together, with the rest of the lateral 



Fig. 129. 




Osteo-malttcic Pelvis. 



pelvic wall, so that the outlet is greatly deformed as well as the brim 
(Fig. 130). 

Fig. 130. 




Extreme Degree of Osteo-malacic Deformity. 

Ohliquely Contracted Pelvis. — That form of deformity in which one 
oblique diameter only is lessened, has received considerable attention, 
from having been made the subject of special study by Kaegele, and 
is generally known as the ohliquely contracted pelvis (Fig. 131). It is 
a condition that is very rarely met with, although it is interesting 
from an obstetric point of view, as throwing considerable light on 
the mode in which the natural development of the pelvis is effected. 
It is difficult to diagnose, inasmuch as there is no apparent external 
deformity, and probably it has never, in fact, been detected before 
delivery. It has a very serious influence on labor ; Litzmann found 
that out of 28 cases of this deformity, 22 died in their first labors, 



374 



LABOR 



Fig. 131. 




Obliquely Contracted Pelvis. (After 
Duncan.) 



and 5 more in subsequent deliveries. The prognosis, therefore, is 
very formidable, and renders a knowledge of this distortion, rare 
though it be, of much importance. 

Its essential characteristic is flattening and want of development 
of one side of the pelvis, associated with anchylosis of the corre- 
sponding sacro-iliac synchondrosis. 
The latter is probably always present, 
and it seems to be most generally a 
congenital malformation. The lateral 
half of the sacrum on the same side, 
and the entire innominate bone are 
much atrophied. The promontory of 
the sacrum is directed towards the 
diseased side, and the symphysis pubis 
is pushed over towards the healthy 
side. 

The main agent in the production 
of this deformity is the absence of the 
sacro-iliac joint, which prevents the 
proper lateral expansion of the pelvic 
brim on that side, and allows the 
counter-pressure, through the femur, to push in the atrophied os 
innominatum to a much greater extent than usual. The chief dimi- 
nution in the length of the pelvic diameter is between the ilio-pec- 
tineal eminence of the affected side and the healthy sacro-iliac joint; 
while the oblique diameter between the anchylosed joint and the 
healthy os innominatum is of normal length. 

Narrowing of the Transverse Diameter. — Transverse contraction ol 
the pelvic brim is very much less common than narrowing of the 
conjugate diameter. It most frequently depends on backward cur- 
vature of the lower parts of the spinal column, in consequence of 
disease of the vertebras. This form of deformed pelvis is generally 
known as the kyphotic. The effect of the spinal curvature is to drag 
the promontory of the sacrum backwards, so that it is high up and 
out of reach. By this means the antero-posterior diameter of the 
brim is increased, while the transverse is lessened ; the relative pro- 
portion between the two is thus reversed. While the upper propor- 
tion of the sacrum is displaced backwards, its lower end is projected 
forward, so that the antero-posterior diameters of the cavity and 
outlet are considerably diminished. The ischial tuberosities are also 
nearer to each other, and the pubic arch is narrowed. Obstruction 
to delivery wiil be chiefly met with at the lower parts and outlet of 
the pelvic cavity ; for, although the transverse diameter of the brim 
is narrowed, there is generally sufficient space for the passage of the 
head. 

Robertas Pelvis. — Another form of transversely contracted pelvis 
is known as Robert's pelvis (Fig. 132), having been first described by 
Robert, of Coblentz. It is in fact a doable obliquely contracted 
pelvis, depending on anchylosis of both sacro-iliac joints, and conse- 
quent defective development of the innominate bones. The shape 



DEFORMITIES OF THE PELVIS. 



375 



Fig. 132. 




Robert's or Double Obliquely Contracted 
Pelvis. (After Duncan.) 



of the pelvic brim is markedly oblong, and the sides of the pelvis 
are more or less parallel with each other. The outlet is also much 
contracted transversely. The amount 
of obstruction is very great, so that, 
according to Schroeder, out of 7 well- 
authenticated cases the Cesarean 
section was required in 6. 

Deformity from Old- standing Hip- 
joint Disease. — Another cause of 
transverse deformity, occasionally 
met with, is luxation of the head of 
the femur, depending on old-standing 
joint disease. The head of the femur, 
in this case, presses on the innominate 
bone at the site of dislocation, and 
the result is that the iliac fossa on 
the affected side, or both if the acci- 
dent happens on both sides, is pushed inwards, the transverse diam- 
eter of the brim being lessened. The tuberosity of the ischium is, 
however, projected outwards, so that the outlet of the pelvis is 
increased rather than diminished. 

Deformity from Tumors, Fractures, etc. — Obstruction of the pelvic 
cavity from exostosis or other forms of tumors growing from the 
bones is of great rarity (Fig. 133). 
It may, however, produce very 
serious dystocia, Several curious 
examples are collected in Mr. "Wood's 
article on the pelvis, in some of which 
the obstruction was so great as to 
necessitate the Ceesarean section. 1 
Some of these growths were true 
exostoses; others osteo-sarcomatous 
tumors attached to the pelvic bones, 
most generally the upper part of the 
sacrum; and others were malignant. 
In some cases spiculae of bone have 
developed about the linea ilio-pec- 
tinea or other parts of the pelvis, 
which may not be sufficient to pro- 
duce obstruction, but which may 
injure the uterus, or even the foetal 
head, when they are pressed upon 
them. Irregular projections may 
also arise from the callus of old 
fractures of the pelvic bones. All such cases defy classification, and 
differ so greatly in their extent, and in their effect on labor, that no 



Fig. 133. 




Bony Growth from Sacrum obstructing the 
Pelvic Cavity. 



\} Eight women having pelvic exostoses have been operated upon by Csesarean 

section in the United States, with four recoveries. — Ed.] 



376 LABOR. 

rules can be laid down for them, and each must be treated on its own 
merits. 

Effects of Contracted Pelvis in Labor. — The effects of pelvic con- 
tractions on labor vary, of course, greatly with the amount and 
nature of the deformity; but they must always give rise to anxiety, 
and, in the graver degrees, they produce the most serious difficulties 
we have to contend with in the whole range of obstetrics. 

Nature of Uterine Action in Pelvic Deformity. — In the lesser degrees, 
in which the proportion between the presenting part and the pelvis 
is only slightly altered, we may observe little abnormal beyond a 
greater intensity of the pains, and some protraction of the labor. It 
is generally observed that the uterine contractions are strong and 
forcible in cases of this kind, probably because of the increased 
resistance they have to contend against; and this is obviously a 
desirable and conservative occurrence, which may, of itself, suffice 
to overcome the difficulty. The first stage, however, is not infre- 
quently prolonged, and the pains are ineffective, for the head does 
not readily engage in the brim, the uterus is more mobile than in 
ordinary labors, and it probably acts at a disadvantage. 

Pish to the Mother. — In the more serious cases, the mother is sub- 
jected to many risks, directly proportionate to the amount of obstruc- 
tion and the length of the labor. The long- continued and excessive 
uterine action, produced by the vain endeavors to push the child 
through the contracted pelvic canal, the more or less prolonged con- 
tusion and injury to which the maternal soft parts are necessarily 
subjected (not unfrequently ending in inflammation and sloughing 
with all its attendant dangers), and the direct injury which may be 
inflicted by the measures we are compelled to adopt for aiding de- 
livery (such as the forceps, turning, craniotomy, or Caesarean section), 
all tend to make the prognosis a matter of grave anxiety. 

Pish to the Child. — Nor are the dangers less to the child; and a 
very large proportion of still-births will always be met with. The 
infantile mortality may be traced to a variety of causes, the most 
important being the protraction of the labor, and the continuous 
pressure to which the presenting part is subjected. For this reason, 
even in cases in which the contraction is so slight that the labor is 
terminated by the natural powers, it has been estimated that 1 out 
of every 5 children is still-born ; and as the deformity increases in 
amount, so, of course, does the prognosis to the child become more 
unfavorable. 

Frequent Occurrence of Prolapse of the Cord. — Prolapse of the 
umbilical cord is of very frequent occurrence in cases of pelvic de- 
formity, the tendency to this accident being traceable to the fact of 
the head not entering and occupying the upper strait of the pelvis 
as in ordinary labors, and thus leaving a space through which the 
cord may descend. So frequently is this complication met with in 
pelvic deformity that Stanesco 1 found it had happened as often as 59 
times in 414 labors ; and when the dangers of prolapsed funis are 

1 Op. cit. p. 94. 



DEFORMITIES OF THE PELVIS. 377 

added to those of protracted labors, it is hardly a matter of surprise 
that the occurrence should, under such circumstances, almost always 
prove fatal to the child. 

Injury to Child's Head. — The head of the child is also liable to 
injury of a more or less grave character from the compression to 
which it is subjected, especially by the promontory of the sacrum. 
Independently of the transient effects of undue pressure (temporary 
alteration of the shape of the bones and bruising of the scalp), there 
is often met with a more serious depression of the bones of the skull, 
produced by the sacral promontory. This is most marked in cases 
in which the head has been forcibly dragged past the projecting bone 
by the forceps, or after turning. The amount of depression varies 
with the degree of contraction ; but sometimes, were it not for the 
yielding of the bones of the foetal skull in this way, delivery, Avith- 
out lessening the size of the head by perforation, would be impossi- 
ble. Such depressions are found at the spot immediately opposite 
the promontory, generally at the side of the skull near the junction 
of the frontal and parietal bones. Sometimes there is a slight per- 
manent mark, but more often the depression disappears in a few 
days. The prognosis to the child is, however, grave, when the con- 
traction has been sufficient to indent the skull ; for it has been found 
that 50 per cent, of the children thus marked died either immediately 
or shortly after labor. 1 

Course of Labor. — The means which nature takes to overcome these 
difficulties are well worthy of study, and there are certain peculiari- 
ties in the mechanism of delivery when pelvic deformities exist, 
which it is of importance to understand, as they guide us in deter- 
mining the proper treatment to adopt. 

Frequency of MaJpresentation. — Malpresentations of the foetus are 
of much more frequent occurrence than in ordinary labors ; partly 
because the head does not engage readily in the brim, but, remaining 
free above it, is apt to be pushed away by the uterine contractions ; 
and partly because of the frequent alteration of the axis of the 
uterine tumor. The pendulous condition of the abdomen in cases 
of pelvic deformity is often very obvious, so that the fundus is 
sometimes almost in a line with the cervix, and thus transverse or 
other abnormal positions are very frequently met with. It is to be 
noted, however, that we cannot regard breech presentations as so 
unfavorable as in ordinary labors, for the pressure from the con- 
tracted pelvis is less likely to be injurious Avhen applied to the body 
than to the head of the child ; and indeed, as we shall presently see, 
the artificial production of these presentations is often advisable as a 
matter of choice. 

Mechanism of Delivery in Head Presentations. — The mode in which 
the head passes naturally through a contracted pelvis is in some re- 
spects different from the ordinary mechanism of delivery in bead 
presentations, and has been carefully worked out by Spiegelberg, 
and other German obstetricians. 

1 Schroeder, op. cit. p. 256. 
25 



378 LABOR. 

The means which nature adopts to overcome the difficulty are dif- 
ferent in cases in which there is a marked narrowing of the conju- 
gate diameter of the brim, and in those in which there is a generally 
contracted pelvis. 

In Contracted Brim. — In the former, and more common deformity, 
when the head enters the brim, in consequence of the resistance it 
meets with, the expelling power of the uterus acts more on the ante- 
rior part of the head than in ordinary cases, the chin becomes in 
some degree separated from the sternum, and the anterior fontanelle 
descends somewhat lower than the posterior. At this stage, on ex- 
amination, it will be found — supposing we have to do with a case in 
which the occiput points to the left side of the pelvis — that the inte- 
rior fontanelle is lower than the posterior, and to the right, the bi- 
temporal diameter of the head is engaged in the conjugate diameter 
of the brim (as the smallest diameter of the skull, there is manifest 
advantage in this), the bi-parietal diameter and the largest portion 
of the head points to the left side. The sagittal suture will be felt 
running across in the transverse diameter of the brim, but nearer to 
the sacrum, the head being placed obliquely. As the head is forced 
down by the uterine contractions, the parietal bone, which is resting 
on the promontory, is pushed against it, so that the sagittal suture 
is forced more into the true transverse diameter of the pelvic brim, 
and approaches nearer to the pubis. The next step is the depression 
of the head, the occiput undergoing a sort of rotation on its trans- 
verse axis, so that it reaches a plane below the brim. When this is 
accomplished, the rest of the head readily passes the obstruction. 
The forehead now meets with the resistance of the pelvic walls, the 
posterior fontanelle descends to a lower level, and, as the cavity of 
the pelvis in cases of antero-posterior contraction of the brim is 
generally of normal dimensions, the rest of the labor is terminated 
in the usual way. 

In generally Contracted Pelvis. — In the generally contracted pelvis 
the head enters the brim with the posterior fontanelle lowest, and it 
is after it has engaged in it that the resistance to its progress becomes 
manifest. The result is, therefore, an exaggeration of what is met 
with in ordinary cases. The resistance to the anterior or longer arm 
of the lever is greater than that to the occipital or shorter ; and, 
therefore, the flexion of the head becomes very marked. The pos- 
terior fontanelle is consequently unusually depressed, and the ante- 
rior quite out of reach. So the head is forced down as a wedge, and 
its further progress must depend upon the amount of contraction. 
If this be not too great the anterior fontanelle eventually descends, 
and delivery is completed in the usual way. Should the contraction 
be too much to permit of this, the head becomes jammed in the 
pelvis, and diminution of its size may be essential. 

In cases of deformity of the conjugate diameter, combined with 
general contraction of the pelvis, the mechanism partakes of the pe- 
culiarities of both these classes, to a greater or less extent, in pro- 
portion to the preponderance of one or other species of deformity. 



DEFORMITIES OF THE PELVIS. 379 

Diagnosis. — It rarely happens that deformities of the pelvis, ex- 
cept of the gravest kind, are suspected before labor has actually 
commenced ; and, therefore, we are not often called upon to give an 
opinion as to the condition of the pelvis before delivery. Should 
we be so, there are various circumstances which may aid us in ar- 
riving at a correct conclusion. Prominent among them is the history 
of the patient in childhood. If she is known to have suffered from 
rickets in early life, more especially if the disease has left evident 
traces in deformities of the limbs, or in a dwarfed and stunted growth, 
or in curvature of the spine, there will be strong presumptive evi- 
dence of pelvic deformity ; a markedly pendulous state of the abdo- 
men may also tend to confirm the suspicion. Nothing short of a 
careful examination of the pelvis itself will, however, clear up the 
point with certainty ; and, even by this means, to estimate the pre- 
cise degree of deformity with accuracy requires considerable skill 
and practice. The ingenuity of practitioners has been much exer- 
cised, it might perhaps be justly said, wasted, in the invention of 
various more or less complicated pelvimeters for aiding us in obtain- 
ing the desired object. It is, however, pretty generally admitted by 
all accoucheurs, that the hand forms the best and most reliable in- 
strument for this purpose, at any rate as regards the interior of the 
pelvis ; although a pair of callipers, such as Baudelocque's well-known 
instrument, is essential for accurately determining the external meas- 
urements. The objections to all internal pelvimeters, even those most 
simple in their construction, are their cost and complexity, and the 
impossibility of using them without pain or injury to the patient. 

External Measurements. — It was formerly thought that by measur- 
ing the distance between the spinous processes of the sacrum and the 
symphysis pubis, and subtracting from it what we judge to be the 
thickness of the bones and soft parts, we might arrive at an approxi- 
mate estimate of the measurement of the conjugate diameter of the 
pelvic brim. It is now admitted that this method can never be de- 
pended on, and that it is practically useless. [In a case of rachitic 
deformity where the conjugate diameter measured 2 J inches, the ex- 
ternal sacro-pubic measurement was an inch over the normal. — Ed.] 
A change in the relative length of other external measurements of 
the pelvis is, however, often of great value in showing the existence 
of deformity internally, although not in judging of its amount. The 
measurements which are used for this purpose are between the 
anterior superior spines of the ilia, and between the centres of their 
crests, averaging respectively 9J and 10J inches. According to 
Spiegelberg these measurements may give one of three results. 

1. Both may be less than they ought to be, but the relation of the 
one to the other remains unchanged. 

2. That between the crests is not, or is at most very little, dimin- 
ished, but that between the spines is increased. 

3. Both are diminished, but at the same time their mutual relation 
is not normal, the distance between the spines being as long, if not 
longer, than that between the crests. 



380 



LABOR. 



No. 1 denotes a uniformly contracted pelvis. No. 2, a pelvis 
simply contracted in the conjugate diameter of the brim, and not 
otherwise deformed. No. 3, a pelvis with narrowed conjugate and 
also uniformly contracted, as in the severe type of rachitic de- 
formity. 

Besides the above some information may be obtained by the 
measurement of the external conjugate diameter, which averages 
7f inches. This may be taken by placing one point of the callipers 
in the depression below the spine of the last lumbar vertebra, the 
other at the centre of the upper edge of the symphysis pubis. If the 
measurement be distinctly below the average, we may conclude that 
there is a narrowing of the antero-posterior diameter of the brim, 
the extent of which we must endeavor to ascertain by other means. 
For the purpose of making these measurements Baudelocque's 
compas d'epaisseur can be used, or Dr. Lazarewitch's elegant universal 
pelvimeter, which can be adopted also for internal pelvimetry; but, 
in the absence of these special contrivances, an ordinary pair of calli- 
pers, such as are used by carpenters, can be made to answer the 
desired object. 

Internal Measurements. — -These external measurements must be 
corroborated by internal, chiefly of the antero-posterior diameter, by 

which alone we can estimate the 
F IG - 134. amount of the deformity. We en- 

deavor to find, in the first place, the 
length of the diagonal conjugate, 
between the lower edge of the sym- 
physis pubis and the promontory 
of the sacrum, which averages 
about half an inch more than the 
true conjugate. The patient lying- 
in the usual obstetric position, or 
still better lying transversely across 
the bed, with her hips raised, an 
attempt is made to reach the pro- 
montory of the sacrum with the tip 
of the index finger. In a health}- 
pelvis this is impossible, so that 
the mere fact of our being able to 
do so proves the existence of 
contraction. A mark is made 
with the nail of the index of the 
left hand on that part of the ex- 
amining finger which rests under 
the symphysis, and then the dis- 
tance from this to the tip of the finger, less half an inch, may 
be taken to indicate the measurement of the true conjugate of the 
brim. Various pelvimeters are meant to make the same measure- 
ments, such as Lumley Earle's, Lazarewitch's, which is similar in 
principle, and Van Huevel's; the best and simplest, I think, is 
that invented by Dr. Greenhalgh (Fig. 134). It consists of a mov- 




Greenhalgh's Pelvimeter 



DEFORMITIES OF THE PELVIS. 381 

able rod, attached to a flexible band of metal which passes around 
the palm of the examining hand. At the distal end of the rod 
is a curved portion, which passes over the radial edge of the 
index finger. The examination is made in the usual way, and when 
the point of the finger is resting on the promontory of the sacrum, 
the rod is withdrawn until it is arrested by the posterior surface of 
the symphysis, the exact measurement of the diagonal conjugate 
being then read off on the scale. 

It is to be remembered that this procedure is useless in the slighter 

j degrees of contraction, in which the promontory of the sacrum cannot 
be reached. Dr. Eamsbotham proposed to measure the conjugate by 
spreading out the index and middle fingers internally, the tip of one 
resting on the promontory, the other behind the symphysis pubis; 
and then withdrawing them, in the same position, and measuring the 
distance between them. This manoeuvre I believe to be impracticable. 
Whenever, in actual labor, we wish to ascertain the condition of 
the pelvis accurately, . the patient should be anaesthetized, and the 

! whole hand introduced into the vagina (which could not otherwise 
be done without causing great pain), and the proportions of the 
pelvis, and the relations of the head to it, thoroughly explored; and, 
if what has been said as to the mechanism of delivery in these cases 
be borne in mind, this may aid us in determining the kind of de- 
formity existing. In this way contractions about the outlet of the 
pelvis can also be pretty generally made out. 

Mode of Diagnosing the Oblique Pelvis. — The obliquely contracted 
pelvis cannot be determined by any of these methods, but certain 
external measurements, as Naegele has pointed out, will readily 
enable us to recognize its existence. It will be found that measure- 
ments, which in the healthy pelvis ought to be equal, are unequal in 
the obliquely distorted pelvis. The points of measurement are chiefly : 
1. From the tuberosity of the ischium on one side to the posterior 
superior spine of the ilium on the other; 2. From the anterior 
superior iliac spine on the one side to the posterior superior on the 
opposite; 3. From the trochanter major of one side to the posterior 
superior iliac spine on the other; 4. From the lower edge of the 
symph}^sis pubis to the posterior superior iliac spine; 5. From the 
spinous process of the last lumbar vertebra to the anterior superior 
spine of the ilium on either side. 

If these measurements differ from each other by half an inch to an 
inch, the existence of an obliquely deformed pelvis may be safely 
diagnosed. The diagnosis can be corroborated by placing the patient 

1 in the erect position, and letting fall two plumb lines, one from the 
spines of the sacrum, the other from the symphysis pubis. In a 

.healthy pelvis these will fall in the same plane, but in the oblique 

i pelvis the anterior line will deviate considerably towards the un- 
affected side. 

Treatment. — The proper management of labor in contracted pelvis 

i is, even up to this time, one of the most vexed questions in midwifery, 
notwithstanding the immense amount of discussion to which it has 
given rise; and the varying opinions of accoucheurs of equal expe- 



382 LABOK. 

rience afford a strong proof of the difficulties surrounding the subject 
This remark applies, of course, only to the lesser degrees of deformity, 
in which the birth of a living child is not hopeless. When the antero- 
posterior diameter of the brim measures from 2} to 3 inches, it is 
universally admitted that the destruction of the child is inevitable, 
unless the pelvis be so small as to necessitate the performance of the 
Cesarean section. But when it is between 3 inches and the normal 
measurement, the comparative merits of the forceps, turning, and 
the induction of premature labor, form a fruitful theme for discus- 
sion. With one class of accoucheurs the forceps is chiefly advocated, 
and turning admitted as an occasional resource when it has failed ; 
and this indeed, speaking broadly, may be said to have been the 
general view held in this country. More recently we find German 
authorities of eminence, such as Schroeder and Spiegelberg, giving 
turning the chief place, and condemning the forceps altogether in 
contracted pelvis, or, at least, restricting its use within very narrow 
limits. More strangely still we find, of late, that the induction of 
premature labor, on the origination and extension of which British 
accoucheurs have always prided themselves, is placed without the 
pale, and spoken of as injurious and useless in reference to pelvic 
deformities. To see our way clearly amongst so many conflicting 
opinions is by no means an easy task, and perhaps we may best aid 
in its accomplishment by considering separately the three operations 
in so far as they bear on this subject, and pointing out briefly what 
can be said for and against each of them. 

The Forceps. — In England and in France it is pretty generally 
admitted that in the slighter degrees of contraction the most reliable 
means of aiding the patient is by the forceps. It should be remem- 
bered that the operation, under such circumstances, is always much 
more serious than in ordinary labors simply delayed from uterine 
inertia, when there is ample room, and the head is in the cavity of 
the pelvis ; for the blades have to be passed up very high, often when 
the head is more or less movable above the brim, and much more 
traction is likely to be required. For these reasons artificial assist- 
ance, when pelvic deformity is suspected, is not to be lightly or 
hurriedly resorted to. Nor fortunately is it always necessary ; for 
if the pains be sufficiently strong, and the contraction not too great 
to prevent the head engaging at all, after a lapse of time it will be- 
come so moulded in the brim as to pass even a considerable obstruc- 
tion. In all cases, therefore, sufficient time must be given for this ; 
and if no suspicious symptoms exist on the part of the mother — no 
elevation of temperature, dryness of the vagina, rapid pulse, and the 
like, and the foetal heart-sounds continue to be normal — labor may 
be allowed to go on for some hours after the rupture of the mem- 
branes, so as to give nature a chance of completing the delivery. 
When this seems hopeless, the intervention of art is called for. 

Cases Suitable for the Forceps. — The forceps is generally considered 
to be applicable in all degrees of contraction, from the standard 
measurement, down to about 3 J inches in the conjugate of the brim. 



DEFORMITIES OF THE PELVIS. 383 

There can be no doubt that, in such cases, traction with the forceps 
often enables us to effect delivery, when the natural efforts have 
proved insufficient, and holds out a very fair hope of saving the 
child. Out of 17 cases in which the high forceps operation was re- 
sorted to for pelvic deformity, reported by Stanesco, in 13 living 
children were born. If the length of the labor, and the long-con- 
tinued compression to which the child has been subjected, be borne 
in mind, this result must be considered very favorable. 

Objections that have been raised to the Forceps. — What are the ob- 
jections which have been brought against the operation ? These have 
been principally made by Schroeder and other German writers. 
They are, chiefly the difficulty in passing the instrument ; the risk 
of injuring the maternal structures ; and the supposition that, as the 
blades must seize the head by the forehead and occiput, their com- 
pressive action will diminish its longitudinal and increase its trans- 
verse diameter (which is opposed to the contracted part of the brim), 
and so enlarge the head just where it ought to be smallest. There 
is little doubt that these writers much exaggerate the compressive 
power of the forceps. Certainly with those generally used in this 
country, any disadvantage likely to accrue from this is more than 
counterbalanced by the traction on the head ; and the fact, that 
minor degrees of obstruction can be thus overcome, with safety both 
to the mother and child, is abundantly proved by the numberless 
cases in which the forceps have been used. 

It is not equally Suitable in all hinds of Deformity. — It is very likely 
that the forceps do not act equally well in all cases. When the head 
is loose above the brim ; when the contraction is chiefly limited to 
the antero-posterior diameter, and there is abundance of room at the 
sides of the pelvis for the occiput to occupy after version; and when, 
as is usual in these cases, the anterior fontanelle is depressed and the 
head lies transversely across the brim, it is probable that turning 
may be the safer operation for the mother, and the easier performed. 
When, on the other hand, the head has engaged in the brim, and has 
become more or less impacted, it is obvious that version could not be 
performed without pushing it back, which may neither be easy nor 
safe. In the generally contracted pelvis, in which the head enters in 
an exaggerated state of flexion and lies obliquely, the posterior fon- 
tanelle being much depressed, the forceps are more suitable. 

Mechanical Advantage of Turning in certain Cases. — The special 
reasons why version sometimes succeeds when the forceps fails, or 
why it may be elected from the first as a matter of choice, have been 
by no one better pointed out than by Sir James Simpson. Although 
the operation was performed by many of the older obstetricians, its 
revival in modern times, and the clear enunciation of its principles, 
can undoubtedly be traced to his writings. He points out that the 
head of the child is shaped like a cone, its narrowest portion the 
base of the cranium (Fig. 135, bb), measuring, on an average, from 
J to f of an inch less than the broadest portion (Fig. 135, aa), viz., 
the bi-parietal diameter. In ordinary head presentations the latter 



:84 



LABOR 



Fig. 135. 




Section of Foetal Cranium, show 
ing its Conical Form. 

Fig. 136. 



part of the head has to pass first; but if the feet are brought down, 
the narrow apex of the cranial cone is brought first into apposition 
with the contracted brim, and can be more 
easily drawn through than the broader base 
can be pushed through by the uterine con- 
tractions. Nor is this the only advantage, 
for after turning the narrower bi- temporal 
diameter (Fig. 136, bb) — which measures, on 
an average, half an inch less than the bi- 
parietal (Fig. 136, aa) — is brought into con- 
tact with the contracted conjugate, while the 
broader bi-parietal lies in the comparatively 
wide space at the side of the pelvis (Fig. 137). 
These mechanical considerations are suffici- 
ently obvious, and fully explain the success 
which has often attended the performance of 
the operation. 

Limits of the Operation. — It is generally 
admitted that it may be possible, for the rea- 
sons just mentioned, to deliver a living child 
by turning, through a pelvis contracted be- 
yond the point which would permit of a living 
child being extracted by the forceps. Many 
obstetricians believe that it is possible to de- 
liver a living child by turning in a pelvis 
contracted even to the extent of 2f inches in 
the conjugate diameter. Barnes maintains 
that, although an unusually compressible 
head may be drawn through a pelvis con- 
tracted to 3 inches, the chance of the child 
being born alive under such circumstances 
must necessarily be small, and that from 3J inches to the normal size 
must be taken as the proper limits of the operation. 




Showing the greater breadth of 
the Bi-parietal Diameter of 
the Foetal Cranium. (After 
Simpson.) 



Fig. 137. 




Showing the greater space for the Bi-parietal Diameter at the side of the Pelvis in certain 
cases of Deformity. (After Simpson.) 

That delivery is often possible by turning, after the forceps and 
the natural powers have failed, and when no other resource is left 
but the destruction of the child, must, I think, be admitted by all ; 



DEFORMITIES OF THE PELVIS. 385 

for the records of obstetrics are full of such cases. To take one ex- 
ample only, Dr. Braxton Hicks 1 records four cases in which the for- 
ceps were tried unsuccessfully, in all of which version was used, 
three of the children being born alive. Here are the lives of three 
children rescued from destruction, within a short period, in the 
practice of one man ; and a fact like this would, of itself, be ample 
justification of the attempt to deliver by turning, when the child was 
known to be alive, and other means had failed. The possibility that 
craniotomy may still be required is no argument against the opera- 
tion ; for, although perforation of the after- coming head is certainly 
not so easy as perforation of a presenting head, it is not so much 
more difficult as to justify the neglect of an expedient by which it 
may possibly be altogether avoided. 

Comparative Estimate of the Two Operations. — The original choice 
of turning is a more difficult question to decide. My own impression 
is that the use of the forceps will generally be found to be preferable. 
An exception should, I think, be made for those cases in which the 
head refuses to enter the brim, and cannot be sufficiently steadied 
by external pressure to admit of an easy application of the instru- 
ment. Under these circumstances increasing experience leads me to 
prefer turning as decidedly the simpler and safer operation, and the 
passage of the head through the contracted brim can be very mate- 
rially facilitated by strong pressure from above, as has been so well 
pointed out by Groodell. 2 

An argument used by Martin, of Berlin, 3 in reference to the two 
operations, should not be lost sight of, as it seems to be a valid reason 
for giving a preference to the forceps. He points out that moulding- 
may safely be applied for hours to the vertex ; but that when pres- 
sure is applied to the important structures about the base of the 
brain, as after turning, moulding cannot be continued beyond five 
minutes without proving fatal. This, however, is no reason why 
turning should not be used after the forceps and the natural efforts 
have proved ineffectual. 

Craniotomy or the Csesarean Section is required. — -When the con- 
traction is below 3 inches in the conjugate, or when the forceps and 
turning have failed, no resource is left but the destruction of the 
foetus, or the Caesarean section. 

The induction of premature labor as a means of avoiding the risks 
of delivery at term, and of possibly saving the life of the child, must 
now be studied. The established rule, in this country, is, that in all 
cases of pelvic deformity, the existence of which has been ascertained 
either by the experience of former labors, or by accurate examina- 
tion of the pelvis, labor should be induced previous to the full period, 
so that the smaller and more compressible head of the premature 
foetus may pass, where that of the foetus at term could not. The 
gain is a double one, partly the lessened risk to the mother, and 
partly the chance of saving the child's life. 

1 Guy's Hosp. Rep. 1870. 2 Amer. Journ. of Obst., vol. viii. 

3 Mon. f. Gebert. 1867. 



386 LABOR. 

The practice is so thoroughly recognized as a conservative and 
judicious one, that it might be deemed unnecessary to argue in its 
favor, were it not that some most eminent authorities have of late 
years tried to show, that it is better and safer to the mother to leave 
the labor to come on at term ; and that the risk to the child is so 
great in artificially induced labor as to lead to the conclusion that 
the operation should be altogether abandoned, except, perhaps, in 
the extreme distortion in which the Csesarean section might other- 
wise be necessary. Prominent amongst those who hold these views 
are Spiegelberg and Litzmann, and they have been supported, in a 
modified form, by Matthews Duncan. Spiegelberg 1 tries to show, 
by a collection of cases from various sources, that the results of in- 
duced labor in contracted pelvis are much more unfavorable than 
when the cases are left to nature ; that in the latter the mortality of 
the mothers is 6.Q per cent., and of the children 28.7 per cent., whereas 
in the former the maternal deaths are 15 per cent., and the infantile 
66.9 per cent. Litzmann 2 arrives at not very dissimilar results, 
namely, 6.9 per cent, of the mothers and 20.3 per cent, of the children 
in contracted pelvis at term, and 14.7 per cent, of the mothers and 
55.8 per cent, of the children, in artificially induced premature labor. 

If these statistics were reliable, inasmuch as they show a very 
decided risk to the mother, there might be great force in the argu- 
ment that it would be better to leave the cases to run the chance of 
delivery at term. It is, however, very questionable whether they 
can be taken, in themselves, as being sufficient to settle the question. 
The fallacy of determining such points by a mass of heterogeneous 
cases, collected together without a careful sifting of their histories, 
has over and over again been pointed out ; and it would be easy 
enough to meet them by an equal catalogue of cases in which the 
maternal mortality is almost nil. The results of the practice of 
many authorities are given in Churchill's work, where Ave find, for 
example, that out of 46 cases of Merriman's, not one proved fatal. 
The same fortunate result happened in 62 cases of Rambotham's. 
His conclusion is, that " there is undoubtedly some risk incurred by 
the mother, but not more than by accidental premature labor," and 
this conclusion, as regards the mother, is that which has long ago 
been arrived at by the majority of British obstetricians, who un- 
doubtedly have more experience of the operation than those of any 
other nation. With regard to the child, even if the German statis- 
tics be taken as reliable, they would hardly be accepted as contra- 
indicating the operation, inasmuch as it is intended to save the mother 
from the dangers of the more serious labor at term, and, in many 
cases, to give at least a chance to the child, whose life would other- 
wise be certainly sacrificed. The result, moreover, must depend to a 
great extent on the method of operation adopted, for many of the 
plans of inducing labor recommended are certainly, in themselves, 
not devoid of danger both to the mother and the child. It may, I 

1 Arch. f. Gyn. b. i. s. 1. 2 lb. b. ii. s. 169. 



DEFORMITIES OF THE PELVIS. 387 

think, be admitted, as Duncan contends, 1 that the operation has 
been more often performed than is absolutely necessary, and that the 
higher degrees of pelvic contraction are much more uncommon than 
has been supposed to be the case. That is a very valid reason for 
insisting on a careful and accurate diagnosis, but not for rejecting an 
operation which has so long been an established and favorite re- 
source. 

Determination of Period for Inducing Labor. — When the induc- 
tion of labor has been determined on, the precise period at which it 
should be resorted to becomes a question for anxious consideration, 
for the longer it is delayed the greater, of course, are the dangers for 
the child. Many tables have been constructed to guide us on this 
point, which, are not, on the whole, of so much service as they might 
appear to be, on account of the difficulty of determining with minute 
accuracy the amount of contraction. The following, however, which 
is drawn up by Kiwisch, may serve for a guide in settling this ques- 
tion : — ■ 









Inches. 


Lines. 






When the 


sacro-pubic 


diameter 


is 2 

2 


md 


6 or 7 
8 " 9 


induce labo 
u it 


r at 30th week. 
31st " 


(C 




It 


2 


it 


10 " 11 


" ' 


32d " 


(( 




IC 


3 


It 


— 


it I 


33d ' ; 


u 




It 


3 


a 


1 


U i 


33d " 


u 




u 


3 


a 


2 " 3 


It I 


34th " 


C( 




u 


3 


a 


4 " 5 


11 i 


35th " 


(( 




u 


3 


tt 


5 " 6 


11 I 


36th " 



In cases of moderate deformity, when labor pains have been in- 
duced, the further progress of the case may be left to nature ; but, 
in the more marked cases, as in those below 3 inches, it will often 
be found necessary to assist delivery by turning or by the forceps, 
the former being here specially useful, on account of the extreme 
pliability of the head, and the facility with which it may be drawn 
through the contracted brim. By thus combining the two operations 
it may be quite possible to secure the birth of a living child even in 
pelves very considerably deformed. 

Production of Abortion in extreme Deformity . — 'When the contraction 
is so great as to necessitate the induction of the labor before the sixth 
month, or, in other words, before the child has reached a viable age, 
it would be preferable to resort to a very early production of abor- 
tion. The operation is then indicated, not for the sake of the child, 
but to save the mother from the deadly risk to which she would 
otherwise be subjected. As, in these cases, the mother alone is con- 
cerned, the operation should be performed as soon as we have posi- 
tively determined the existence of pregnancy. No object can be 
gained by waiting until the development of the child is advanced to 
any extent, and the less the foetus is developed, the less will be the 
pain and risks the mother has to undergo. There is no amount of 
deformity, however great, in which we could not succeed in bringing 

1 Edin. Med. Journ., July, 1873, p. 339. 



388 LABOR. 

on miscarriage by some of the numerous means at our disposal ; and, 
in spite of Dr. Eadford's objections, who maintains that the obstetri- 
cian is not justified in sacrificing the life of a human being more than 
once, when the mother knows that she cannot give birth to a viable 
child, there are few practitioners who would not deem it their duty 
to spare the mother the terrible dangers of the Cesarean section. 



CHAPTER XIII. 

HEMORRHAGE BEFORE DELIVERY: PLACENTA PREVIA. 

The hemorrhages which are the result of an abnormal situation 
of the placenta, partially or entirely, over the internal os uteri, have 
formed a most fruitful theme for discussion. The causes producing 
the abnormal placental site, the sources of the blood, and the causes 
of its escape, the means adopted by nature for its arrest, and the 
proper treatment, have, each and all of them, been the subject of 
endless controversies, which are not yet by any means settled. It 
must be admitted, too, that the extreme importance of the subject 
amply justifies the attention which has been paid to it; for there is 
no obstetric complication more apt to produce sudden and alarming 
effects, and none requiring more prompt and scientific treatment. 

By placenta prvevia we mean the insertion of the placenta at the 
lower segment of the uterine cavity, so that part of it is situated, 
wholly or partially, over the internal os uteri. In the former case 
there is complete or central placental presentation, in the latter an 
incomplete or marginal presentation. 

Causes. — The causes of this abnormal placental site are not fully 
understood. It was supposed by Tyler Smith to depend on the ovule 
not having been impregnated until it had reached the lower part of 
the uterine cavity. Cazeau suggests that the uterine mucous mem- 
brane is less swollen and turgid than when impregnation occurs at 
the more ordinary place, and that, therefore, it offers less obstruction 
to the descent of the ovule to the lower part of the uterine cavity. 
An abnormal size, or unusual shape, of the uterine cavity may also 
favor the descent of the impregnated ovule; the former probably 
explains the fact, that placenta previa more generally occur in women 
who have borne several children. These are merely interesting specu- 
lations having no practical value, the fact being undoubted that, in 
a not inconsiderable number of cases — estimated hj Johnson and 
Sinclair as 1 out of 573 — the placenta is grafted partially or entirely 
over the uterine orifice. 

History. — Placenta prawia was not unknown to the older writers, 
who believed that the placenta had original^ been situated at the 



HEMORRHAGE BEFORE DELIVERY. 389 

fundus, from which it had accidentally fallen to the lower part of 
the uterus. Portal, Levret, Eoederer, and especially our own country- 
man Rigby, were among those whose observations tended to improve 
the state of obstetrical knowledge as to its real nature. To Rigby 
we owe the term "unavoidable hemorrhage" as a synonym for placenta 
praevia, and as distinguishing hemorrhage from this source from that 
resulting from separation of the placenta at its more usual position, 
termed by him, in contra-distinction, " accidental hemorrhage." These 
names, adopted by most writers on the subject, are obviously mis- 
leading, as they assume an essential distinction in the etiology of the 
hemorrhage in the two classes of cases, which is not always warranted 

It is of the utmost importance to a right understanding of the 
nature and treatment of placenta praevia that we should fully under- 
stand the source of the hemorrhage, and the manner of its produc- 
tion; but we shall be able to discuss this subject better after a 
description of the symptoms. 

Symptoms. — Although the placenta must occupy its unusual site 
from the earliest period of its formation, it rarely gives rise to appre- 
ciable symptoms before the last three months of utero-gestation. It 
is far from unlikely, however, that such an abnormal situation of the 
placenta may produce abortion in the earlier months, the site of its 
attachment passing unobserved. 

Sudden Flow of Blood. — The earliest symptom which causes suspi- 
cion is the sudden occurrence of hemorrhage, without any appreciable 
cause. The amount of blood lost varies considerably. In some cases 
the first hemorrhage is comparatively slight, and is soon spontaneously 
arrested; but, if the case be left to itself, the flow after a lapse of 
time — it may be a few days, or it may be weeks — again commences 
in the same unexpected way, and each successive hemorrhage is more 
profuse. The losses show themselves at different periods. They 
rarely begin before the end of the sixth month, more often nearer 
the full period, and sometimes not until labor has actually com- 
menced. The hemorrhage verv often coincides with what would 
have been a menstrual period; doubtless on account of the physio- 
logical congestion of the uterine organs then present. Should the 
first loss not show itself until at or near the full time, it may be 
tremendous, and a few moments may suffice to place the patient's 
life in jeopardy. Indeed it may be safely accepted as an axiom, that 
once hemorrhage has occurred, the patient is never safe; for excessive 
losses may occur at any moment without warning, and when assist- 
ance is not at hand. It often happens that premature labor comes 
on after one or more hemorrhages. 

In any case of placenta praevia, when labor has commenced, 
whether premature or at the full time, the hemorrhage may become 
excessive, and with each pain fresh portions of placenta may be de- 
tached, and fresh vessels torn and left open. Under these circum- 
stances the blood often escapes in greater quantity with each suc- 
cessive pain, and diminishes in the intervals. This has long been 
looked upon as a diagnostic mark by which we can distinguish be- 
tween the so-called "unavoidable '•' and "accidental " hemorrhage ; 



390 LABOR. 

in the latter the flow being arrested during the pains. The distinc- 
tion, however, is altogether fallacious. The tendency of uterine 
contraction in placenta prsevia, as in all other forms of uterine 
hemorrhage, is to constrict the vessels from which the blood escapes, 
and so to lessen the flow. The apparently increased flow during the 
pains depends on the pains forcing out blood which has already 
escaped from the vessels. In one way, up to a certain point, the 
pains do favor hemorrhage, by detaching fresh portions of placenta ; 
but the actual loss takes place chiefly during the intervals, and not 
during the continuance of contraction. 

Results of Vaginal Examination. — On vaginal examination, if the 
os be sufficiently open to admit the finger, which it generally is on 
account of the relaxation produced by the loss of blood, we shall 
almost always be able to feel some portion of presenting placenta. 
If it be a central implantation, we shall find the upper aperture of 
the cervix entirely covered by a thick, boggy mass, which is to be 
distinguished from a coagulum by its consistence, and by its not 
breaking down under the pressure of the finger. Through the pla- 
cental mass we may feel the presenting part of the foetus ; but not 
as distinctly as when there is no intervening substance. In partial 
placental presentations the bag of membranes, and above it the head 
or other presentation, will be found to occupy a part of the circle of 
the os, the rest being covered by the edge of the placenta. In mar- 
ginal presentations we may only be able to make out the thickened 
edge of the after-birth, projecting at the rim of the os. If the cer- 
vix be high, and the gestation not advanced to term, these points 
may not be easy to make out, on account of the difficulty of reaching 
the cervix ; and, as accurate diagnosis is of the utmost importance, 
it is proper to introduce two fingers, or even the whole hand, so as 
thoroughly to explore the condition of the parts. The lower portion 
of the uterine ovoid may be observed to be more than usually thick 
and fleshy ; and Gendrin has pointed out that ballottement cannot be 
made out. The accuracy of our diagnosis may be confirmed, in 
doubtful cases, by finding that the placental bruit is heard over the 
lower part of the uterine tumor. 

Dr. Wallace 1 has suggested that vaginal auscultation may be ser- 
viceable in diagnosis, and states that, by means of a curved wooden 
stethoscope, the placental bruit may be heard with startling distinct- 
ness. This is, however, a manoeuvre that can hardly be generally 
carried out in actual practice. 

The Source of Hemorrhage. — It is now generally admitted by au- 
thorities that the immediate source of the hemorrhage is the lacerated 
utero-placental vessels. Only a few years ago Sir James Simpson 
advocated, with his usual energy, the theory, sustained by his pre- 
decessor, Dr Hamilton, that the chief, if not the only, source of 
hemorrhage was the detached portion of the placenta itself. He 
argued that the blood flowed from the portion of the placenta which 
was still adherent into that which was separated, and escaped from 

1 Edin. Med. Journ., Nov. 1872. 



HEMORRHAGE BEFORE DELIVERY. 391 

the surface of the latter ; and on this supposition he based his 
practice of entirely separating the placenta, having observed that, in 
many cases in which the after-birth had been expelled before the 
child, the hemorrhage had ceased. The fact of the cessation of the 
hemorrhage, when this occurs, is not doubted; but Simpson's expla- 
nation is contested by most modern writers, prominent among whom 
is Barnes, who has devoted much study to the elucidation of the sub- 
ject. He points out that the stoppage of the hemorrhage is not due 
to the separation of the placenta, but to the preceding or accompany- 
ing contraction of the uterus, which seals up the bleeding vessels, 
just as it does in other forms of hemorrhage. The site of the loss 
was actually demonstrated by the late Dr. Mackenzie in a series of 
experiments, in which he partially detached the placenta in pregnant 
bitches, and found that the blood flowed from the walls of the uterus, 
and not from the detached surface of the placenta. The arrange- 
ment of the large venous sinuses, opening as they do on the uterine 
mucous membrane, favors the escape of blood when they are torn 
across ; and it is from them, possibly to some extent also from the 
uterine arteries, that the blood comes, just as in post-partum hemor- 
rhage, when the whole, instead of a part, of the placental side is bared. 
Causes of Hemorrhage. — Various explanations have been given of 
the causes of the hemorrhage. For long it was supposed to depend 
on the gradual expansion of the cervix during the latter months of 
pregnancy, which separated the abnormally placed placenta. It has 
been seen, however, that this shortening of the cervix is apparent 
only, and that the cervical canal is not taken up into the uterine 
cavity during gestation, or, at all events, only during the last week 
or so. This, therefore, cannot be admitted as an explanation of pla- 
cental separation. Jacquemier proposed another theory which has 
been adopted by Cazeaux. He maintains that during the first six 
months of utero-gestation the superior portion of the uterus is more 
especially developed, as shown by the pyriform shape of the fundus 
during the time; and that, as the placenta is usually attached in that 
situation, and then attains its maximum of development, its relations 
to its attachments are undisturbed. During the last three months of 
pregnancy, on the contrary, the lower segment of the uterus develops 
more than the upper, while the placenta remains nearly stationary 
in size ; the inevitable result being a loss of proportion between the 
cervix and the placenta, and the detachment of the latter. There 
are various objections which can be brought against this theory ; 
the most important being that there is no evidence at all to show 
that the lower segment of the uterus does expand more in proportion 
than the upper during the latter months of pregnancy. Barnes's 
theory is based on the supposition that the loss of relation between 
the uterus and placenta is caused by excess of growth on the part 
of the placenta itself over that of the cervix, which is not adapted 
for its attachment. The placenta, on this hypothesis, grows away 
from the site of its attachment, and hemorrhage results. It will be 
observed that neither this theory, nor that propounded by Jacque- 
mier, are readily reconcilable with the fact that hemorrhage fre- 



392 LABOR. 

quently does not begin until labor has commenced at term. Inasmuch 
as the loss of relation between the placenta and its attachments, 
which they both presuppose, must exist in every case of placenta 
prasvia, hemorrhage should always occur during some part of the 
last three months of pregnancy. Matthews Duncan 1 has recently in- 
vestigated the whole subject at length, and maintains that the hemor- 
rhages are accidental, not unavoidable, being due to precisely similar 
causes as those which give rise to the occasional hemorrhages when 
the placenta is normally placed. The abnormal situation of the pla- 
centa, of course, renders these causes more apt to operate ; but in 
their action he believes them to be precisely similar to those of acci- 
dental hemorrhage, properly so called. Separation of the placenta 
from expansion of the cervix, he believes to be the cause of hemor- 
rhage after labor has begun, and then it may strictly be called una- 
voidable ; but hemorrhage is comparatively seldom so produced 
during the continuance of pregnancy. " There are," says Duncan, 
" four ways in which this kind of hemorrhage may occur : — 

"1. By the rupture of a utero-placental vessel at or about the in- 
ternal os uteri. 

" 2. By the rupture of a marginal utero-placental sinus within the 
area of spontaneous premature detachment, when the placenta is in- 
serted not centrally or covering the internal os, but with a margin at 
or near the central os. 

"3. By partial separation of the placenta from accidental causes, 
such as a jerk or fall. 

" 4. By a partial separation of the placenta, the consequence of 
uterine pains producing a small amount of dilatation of the internal' 
os. Such cases may be otherwise described as instances of miscar- 
riage commencing, but arrested at a very early stage." 

I see no reason to doubt the possibility of hemorrhage being due, 
in many cases, to the first three causes, and in its production it would 
strictly resemble accidental hemorrhage. The fourth heading refers 
the hemorrhage to partial separation, in consequence of commencing 
dilatation of the cervix, but it explains the dilatation by the suppo- 
sition of commencing miscarriage. This latter hypothesis seems to 
be as needless as those which presuppose a want of relation between 
the placenta and its attachments. We know that, quite independ- 
ently of commencing miscarriage, uterine contractions are constantly 
occurring during the continuance of pregnancy. There is reason to 
suppose that these contractions do not affect the cervical, as well as 
the funclal portions of the uterus; and in cases in which the placenta 
is situated partial^ or entirely over the os, one or more stronger 
contractions than usual may, at any moment, produce laceration of 
the placental attachments in that neighborhood. 

Pathological Changes in the Placenta. — A careful examination of 
the placenta may show pathological changes at the site of separation, 
such as have been described by Gendrin, Simpson, and other writers. 
They probably consist of thrombosis in the placental cotyledons, and 

1 Edin. Med. Journ., Nov. 1873, and Brit. Med. Journ., Nov. 1873. 



HEMORRHAGE BEFORE DELIVERY. 393 

effused blood-clots, variously altered and discolorized, according to 
the lapse of time since separation took place. Changes occur in the 
portion of the placenta overlying the os uteri, whether separation 
has occurred or not. There may be atrophy of the placental struc- 
ture in this situation, as well as changes of form, such as complete 
or partial separation into two lobes, the junction of which overlies 
the os uteri. 1 

Natural Termination when Placenta presents. — The history of de- 
livery, if left to nature, is specially worthy of study, as guiding to 
proper rules of treatment. It sometimes happens, when the pains 
are very strong and the delivery rapid, that labor is completed with- 
out any hemorrhage of consequence. "Although," says Cazeaux, 
" hemorrhage is usually considered to be inevitable under such cir- 
cumstances, yet it may not appear even during the labor ; and the 
dilatation of the os uteri may be effected without the loss of a drop 
of blood." Again, Simpson conclusively showed, that when the 
placenta was expelled before the birth of the child, all hemorrhage 
ceased. 

Barnes's theory of placenta previa, which has been pretty gene- 
rally adopted, explains satisfactorily both these classes of cases. 

He describes the uterine cavity as divisible into three zones or 
regions. When the placenta is situated in the upper or middle of 
these zones, no separation or hemorrhage need occur during labor. 
When, however, it is situated partially or entirely in the lower or 
cervical zone, the expansion of the cervix during labor must produce 
more or less separation, and consequent loss of blood. As soon as 
the previous portion of the placenta is sufficiently separated, provided 
contraction of the uterine tissue be present to seal up the mouths of 
the vessels, hemorrhage no longer takes place. The placenta may 
not be entirely detached, but no further hemorrhage occurs, in con- 
sequence of the remaining portion being engrafted on the uterus 
beyond the region of unsafe attachment. 

In the former, then, of these classes of cases, the absence of hemor- 
rhage is explained, on this theory, by the pains being sufficiently 
rapid and strong to complete the separation of the placental attach- 
ment from the lower cervical zone before flooding had taken place ; 
in the latter, it ceases, not necessarily because the entire placenta is 
expelled, but because of its detachment from the area of dangerous 
implantation. 

The amount of cervical expansion required for this purpose varies 
in different cases. Dr. Duncan 2 estimates the limit of the spontaneous 
detaching area to be a circle of 4J inches diameter, and that, after 
the cervix has expanded to that extent, no further separation or 
hemorrhage takes place. To admit of the passage of a full-sized 
head, Barnes estimates that expansion to about a circle of 6 inches 
diameter is necessary ; on the other hand he has sometimes observed 
' " that the hemorrhage has completely stopped when the os uteri had 
' opened to the size of the rim of a wineglass, or even less." 

I 1 Sinelius, Arch. Gen. de Med., vol. ii. 1861. 2 Obst. Trans., vol. xv. 

26 



394 LABOR. 

It will be seen then that in this, as in every other form of peur- 
peral hemorrhage, the tendency of uterine contraction is to check 
the hemorrhage ; and that, provided the pains are sufficiently ener- 
getic, nature may be capable of stopping the flooding without artifi- 
cial aid. It is but rarely, however, that she can be trusted for the 
purpose; and we shall presently see that these theoretical views have 
an important practical bearing on the subject of treatment. 

Prognosis. — The prognosis to both the mother and child is cer- 
tainly grave in all cases of placenta proevia. Eead, in his treatise 
on placenta prasvia, estimates the maternal mortality, from the statis- 
tics of a large number of cases, as 1 in 4J cases, and Churchill as 1 
in 3. This is unquestionably too high an estimate, and based on 
statistics the accuracy of which cannot be relied on. The mortality 
will, of course, greatly depend on the treatment adopted. Doubtless, 
if cases were left to nature, the result would be quite as unfavorable 
as Eead supposes. But if properly managed, much more successful 
results may safely be anticipated. Out of 64 cases, recorded by 
Barnes, the deaths were 6, or 1 in 10J. Under any circumstances 
the risks to the mother are very great. Churchill estimates that 
more than half the children are lost. The reasons for the great 
danger to the child are very obvious, subjected as it is to the risk of 
asphyxia from the loss of the maternal blood, and from its respira- 
tion being carried on during labor by a placenta which is only par- 
tially attached ; many children also perish from prematurity, or from 
mal- presentation. 

Treatment. — Whenever, in the latter months of pregnancy, a sudden 
hemorrhage occurs, the possibility of placenta prasvia will naturally 
suggest itself; and, by a careful vaginal examination, which under 
such circumstances should always be insisted on, the existence of 
this complication will generally be readily ascertained. It is seldom 
that the os is not sufficiently dilated to enable us to satisfy ourselves 
whether the placenta is presenting. 

Is it justifiable to allow the Pregnancy to Continue? — The first ques- 
tion that will arise is, are we justified in temporizing, using means 
to check the hemorrhage, and allowing the pregnancy to continue? 
This is the course which has generally been recommended in works 
on midwifery. We are told to place the patient on a hard mattress, 
not to heat or overburden her with clothes, to keep her absolutely at 
rest, to have the room cool and well-aired, to apply cold cloths to the 
vulva and lower part of the abdomen, to administer cold and acidu- 
lated drinks, in abundance, and to prescribe acetate of lead and 
opium, or gallic acid, on account of their supposed hasmostatic effect. 
Of late years the judiciousness of these recommendations has been 
strongly contested. Not long ago an interesting discussion took 
place at the Obstetrical Society of London, 1 on a paper in which Dr. 
Grecnhalgh advised the immediate induction of labor in all cases of 
placenta praavia. No less than six metropolitan teachers of mid- 
wifery took part in it; and, although they differed in details, they 

1 Obst. Trans., vol. vi. p. 188. 



HEMORRHAGE BEFORE DELIVERY. 395 

all agreed as to the unadvisab'ility of allowing pregnancy to pro- 
gress when the existence of placenta previa had been distinctly 
ascertained. The reasons for this course are obvions and unanswer- 
able. The labor, indeed, very often comes on of its own accord; but 
should it not do so, the patient's life must be considered to be always 
in jeopardy until the case is terminated, for no one can be sure that 
most dangerous, or even fatal, flooding may not at any moment come 
on ; and the nearer to term the patient is, the greater the risk to 
which she is subjected. Xor is the safety of the child likely to be 
increased by delay. Provided it has arrived at a viable age, the 
chances of its being born alive may be said to be greater if preg- 
nancy be terminated at once, than if repeated floodings occur. I 
think, therefore, that it may be safely laid down as an axiom, that 
no attempt should be made to prevent the termination of pregnancy, 
but that our treatment should rather contemplate its conclusion as 
soon as possible. An exception may, however, be made to this rule 
when the hemorrhage occurs for the first time before the seventh 
month of utero-gestation. ' The chances of the child surviving would 
then be very small, and if the hemorrhage be not alarming, as at 
that early period is likely to be the case, the measures indicated 
above may be employed, in the hope of carrying on the pregnancy 
until there is a prospect of the patient being delivered of a living- 
child. But little benefit is likely to accrue from astringent drugs. 
Perfect rest in bed is more likely to be beneficial than anything else ; 
and astringent vaginal pessaries, of matico or perchloride of iron, 
might be used with advantage as local haemostatics. 

Various Methods of Treatment. — When the period of pregnancy, or 
the urgency of the case, determines us to forego any attempt at tem- 
porizing, there are various plans of treatment to be considered. 
These are chiefly — 1. Puncture of the membranes. 2. Plugging the 
vagina. 3. Turning. 4. Partial or complete separation of the placenta. 
It will be well to consider in detail the relative advantages of, and 
indications for, each of these. It is seldom, however, that we can 
trust to any one per se ; in most cases two or more are required to 
be used in combination. 

1. Puncture of the membranes is recommended by Barnes as the 
first measure to be adopted in all cases of placenta praevia, sufficient 
to cause anxiety. "It is," he says, l 'the most generally efficacious 
remedy, and it can always be applied." The primary object gained 
is the increase of uterine contraction, by the evacuation of the liquor 
amnii. Although the first effect of this may be to increase the flow 
of blood by further separation of the placenta, the flooding can 
generally be commanded by plugging, until the os is sufficiently 
dilated to permit the passage of the child. As a rule, there is no 
great difficulty in effecting the puncture, especially if the placental 
presentation be only partial. A quill, or other suitable contrivance, 
guided by the examining finger, is passed through the cervix, and 
pushed through the membranes. In complete placenta praevia it may 
not be so easy to effect the evacuation of the liquor amnii ; and, al- 
though many authorities advise the penetration of the substance of 



396 LABOR. 

the placenta itself, I am inclined to think that it would be better to 
abandon the attempt, in such cases, and trust to other methods of 
treatment. 

The objections which have been raised to puncture of the mem- 
branes are chiefly, that it interferes with the gradual dilatation of 
the os, and renders the operation of turning much more difficult. 
The os is not, however, so regularly dilated by the bag of membranes 
in cases of placenta praevia, as it is in ordinary labors. Moreover, 
the cervical tissues are generally relaxed by the hemorrhage, and 
dilatation is easily effected. Should we desire to dilate the os, pre- 
paratory to turning, we can readily do so by means of Barnes's bags, 
which act, at the same time, as an efficient plug. The objections, 
therefore, are not so weighty as they might have been before these 
artificial dilators were used. I am inclined, for these reasons, to 
agree with the recommendation that puncture of the membranes 
should be resorted to in all cases of placenta previa. 

2. Plugging of the vagina, or, still better., of the cavity of the cer- 
vix itself, is specially serviceable in cases in which the os is not suffi- 
ciently dilated to admit of turning, or of separation of the placenta, 
and in which the hemorrhage still continues after the evacuation of 
the liquor amnii. By means of this contrivance the escape of blood 
is effectually controlled. 

The best way of plugging is to introduce a sponge tent of sufficient 
size into the cervical canal, and to keep it in situ by a vaginal phig; 
the best material for the latter, and the method of introduction, 
are described under the head of abortion. The sponge tent not 
only controls the hemorrhage more effectually than any other means, 
but is, at the same time, effecting dilatation of the cervix. It cannot 
be left in many hours on account of the irritation produced, and of 
the fetor from accumulating vaginal discharges. As long as it is in 
position, we should carefully examine, from time to time, to see that 
no blood is oozing past it. If preferred, a Barnes's bag may be used 
for the same purpose. 

While the plug is in situ, other modes of exciting uterine action 
may be very advantageously employed, such as a firm, abdominal 
bandage, occasional friction over the uterus, and repeated doses of 
ergot. The last is specially recommended by Dr. Greenhalgh, who 
uses, at the same time, a plug formed of an oblong India-rubber ball, 
inflated with air, and covered with spongio-piline. 

On the removal of the plug we may find that considerable dila- 
tation has taken place, perhaps to a sufficient extent to admit of 
labor being safely concluded by the natural efforts. In that case we 
shall find that, although the pains continue, no fresh hemorrhage 
occurs. Should it do so, it will be necessary to adopt further 
measures. 

3. Turning has long been considered the remedy par excellence in 
placenta praevia ; and it is of unquestionable value in suitable cases. 
Much harm, however, has been done when it has been practised be- 
fore the os was sufficiently dilated to admit of the passage of the 
hand, or when the patient was so exhausted by previous hemorrhage 



HEMORRHAGE BEFORE DELIVERY. 397 

as to be unable to bear the shock of the operation. The records of 
many fatal cases in the practice of those who taught, as did the large 
majority of the older writers, that turning at all risks was essential, 
conclusively prove this assertion. 

It is most likely to prove serviceable when, either at first, or after 
the use of the tampon, the os is sufficiently dilated to admit the hand, 
and when the strength of the patient is not much enfeebled. If she 
have a small, feeble, and thready pulse, it is certainly inapplicable, 
unless all other methods of arresting the hemorrhage have failed. 
And, even then, it would be well to attempt to rally the patient from 
her exhausted state by stimulants, etc., before the operation is com- 
menced. 

Provided the placental presentation be partial, the operation can 
be performed without difficulty in the usual way. In central implan- 
tation the passage of the hand may give rise to some difficulty. Dr. 
Eigby recommends that it should be pushed through the substance 
of the placenta, until it reaches the uterine cavity. It is hardly 
possible to conceive how this could be done without completely 
detaching the placenta, and still less to understand how the foetus 
could be dragged through the aperture thus made. It will be far 
better to pass the hand by the border of the placenta, separating it 
as we do so ; and, if we can ascertain to which side of the cervix it 
is least attached, that should be chosen for the purpose. In all cases 
in which it is possible, turning by the bi-polar method should be 
preferred. In cases of placenta praevia especially it offers many ad- 
vantages. The operation can be soon performed; complete dilatation 
of the os is not so necessary; and it involves less bruising of the 
cervix, which is likely to be specially dangerous. When once a foot 
has been brought within the os, the delivery need not be hurried. 
The foot forms a plug, which effectually prevents all further loss; 
and we may then safely wait until we can excite uterine contraction, 
and terminate the labor with safety. Fortunately, the relaxation of 
the uterus, which is so often present, facilitates this manner of per- 
forming version, and it can generally be successfully accomplished. 
Should the case be one which is otherwise suitable for turning, and 
the requisite amount of dilatation of the cervix not be present, the 
latter can generally be effected in the space of an hour or more 
(while at the same time a farther loss of blood is effectually pre- 
vented) by the use of Barnes's bags. 

4. Separation of the Placenta. — Entire separation of the placenta 
was orignally recommended by Simpson in his well-known paper on 
the subject. The reasons which induced him to recommend it have 
already been stated. It is a mistake to suppose, however, as is so 
often done, that he intended to recommend it in all cases alike. This 
supposition he always was careful to deny. He advised it especially : — ■ 

1. When the child is dead. 

2. When the child is not yet viable. 

3. When the hemorrhage is great and the os uteri is not yet suffi- 
ciently dilated for safe turning. This was the state in 11 out of 39 
cases (Lee). 



398 LABOR. 

4. When the pelvic passages are too small for safe and easy 
turning. 

5. When the mother is too exhausted to bear turning. 

6. When the evacuation of the liquor amnii fails. 

7. When the uterus is too firmly contracted for turning. 1 

These are very much the cases in which all modern accoucheurs 
would exclude the operation of turning ; and it was especially when 
that was unsuitable that Simpson advised extraction of the placenta. 
As his theory of the source of hemorrhage is now almost universally 
disbelieved, so has the practice based on it fallen into disuse, and it 
need not be discussed at length. It is very doubtful whether the 
complete separation and extraction of the placenta was a feasible 
operation ; unquestionably it can be by no means so easy as Simp- 
son's writings would lead us to suppose. The introduction of the 
hand far enough to remove the placenta in an exhausted patient 
would probably cause as much shock as the operation of turning 
itself; and another very formidable objection to the procedure is 
the almost certain death of the child, if any time elapse between the 
separation of the placenta and the completion of delivery. The 
modification of this method, so strongly advocated by Barnes, is 
certainly much easier of application, and would appear to answer 
every purpose that Simpson's operation effected. It is impossible to 
describe it better than in Barnes's own words: 2 

" The operation is this : Pass one or two fingers as far as they will 
go through the os uteri, the hand being passed into the vagina if 
necessary ; feeling the placenta, insinuate the finger between it and 
the uterine wall ; sweep the finger round in a circle so as to separate 
the placenta as far as the finger can reach ; if you feel the edge of 
the placenta, where the membranes begin, tear open the membranes 
carefully, especially if these have not been previously ruptured; 
ascertain, if you can, what is the presentation of the child before 
withdrawing your hand. Commonly, some amount of retraction of 
the cervix takes place after the operation, and often the hemorrhage 
ceases. 11 

It will be seen from what has been said that no one rule of prac- 
tice can be definitely laid down for all cases of placenta prgevia. Our 
treatment in each individual case must be guided by the particular 
conditions that are present ; and, if only we bear in mind the natural 
history of the hemorrhage, we may confidently look to a favorable 
termination. 

It may be useful, in conclusion, to recapitulate the rules which 
have been laid down for treatment in the form of a series of pro- 
positions: — 

I. Before the child has reached a viable age, temporize, provided 
the hemorrhage be not excessive, until pregnancy has advanced suffi- 
ciently to afford a reasonable hope of saving the child. For this 
purpose the chief indication is absolute rest in bed, to which other 

1 Selected Obst. Works, p. G8. 2 Obstet. Operations, 2d ed., p. 417. 



HEMORRHAGE BEFORE DELIVERY. 399 

accessory means of preventing hemorrhage, such as cold, astringent 
pessaries, etc., may be added. 

II. In hemorrhage occurring after the seventh month of utero- 
gestation, no attempt should be made to prolong the pregnancy. 

III. In all cases in which it can be easily effected, the membranes 
should be ruptured. By this means uterine contractions are favored, 
and the bleeding vessels compressed. 

IV. If the hemorrhage be stopped, the case may be left to nature. 
If flooding continue, and the os be not sufficiently dilated to admit 
of the labor being readily terminated by turning, the os and the 
vagina should be carefully plugged, while uterine contractions are 
promoted by abdominal bandages, uterine compression, and ergot. 
The plug must not be left in beyond a few hours. 

V. If, on removal of the plug, the os be sufficiently expanded, and 
the general condition of the patient be good, the labor may be ter- 
minated by turning, the bi-polar method being used if possible. If 
the os be not open enough, it may be advantageously dilated by a 
Barnes's bag, which also acts as a plug. 

VI. Instead of, or before resorting to, turning, the placenta may 
be separated around the site of its attachment to the cervix. This 
practice is specially to be preferred when the patient is much ex- 
hausted, and in a condition unfavorable for bearing the shock of 



turning. 



CHAPTEE XIV. 

HEMORRHAGE FROM SEPARATION OF A NORMALLY SITUATED 

PLACENTA. 

This is the form of hemorrhage which is generally described in 
obstetric works as "accidental" in contra-clistinction to the " unavoid- 
able" hemorrhage of placenta praevia. In discussing the latter, we 
have seen that the term "accidental" is one that is apt to mislead, 
and that the causation of the hemorrhage in placenta praevia is, in 
some cases at least, closely allied to that of the variety of hemorrhage 
we are now considering. 

When, from any cause, separation of a normally situated placenta 
occurs before delivery, more or less blood is necessarily effused from 
the ruptured utero-placental vessels, and the subsequent course of 
the case may be twofold. 1. The blood, or at least some part of it, 
may find its way between the membranes and the decidua, and 
escape from the os uteri. This constitutes the typical "accidental" 
hemorrhage of authors. 2. The blood may fail to find a passage 
externaLV, and may collect internally, giving rise to very serious 



400 LABOR. 

symptoms, and even proving fatal, before the true nature of the case 
is recognized. Cases of this kind are by no means so rare as the 
small amount of attention paid to them by authors might lead us to 
suppose; and, from the obscurity of the symptoms and difficulty of 
diagnosis, they merit special study. Dr. Groodell 1 has collected 
together no less than 106 instances in which this complication 
occurred. 

Causes and Pathology. — The causes of placental separation may be 
very various. In a large number of cases it has followed an accident 
or exertion (such as slipping down stairs, stretching, lifting heavy 
weights, and the like), which has probably had the effect of lacerating 
some of the placental attachments. At other times it has occurred 
without such appreciable cause, and then it has been referred to some 
change in the uterus, such as a more than usually strong contraction 
producing separation, or some accidental determination of blood 
causing a slight extravasation between the placenta and the uterine 
wall, the irritation of which leads to contraction and further detach- 
ment. Causes such as these, which are of frequent occurrence, will 
not produce detachment except in women otherwise predisposed to 
it. It generally is met with in women who have borne many child- 
ren, more especially in those of weakly constitution and impaired 
health, and rarely in primiparse. Certain constitutional states proba- 
bly predispose to it, such as albuminuria, or exaggerated anaemia; 
and, still more so, degenerations and diseases of the placenta itself. 

This form of hemorrhage rarely occurs to an alarming extent until 
the latter months of pregnancy, often not until labor has commenced. 
The great size of the placental vessels in advanced pregnancy affords 
a reasonable explanation of this fact. 

Symptoms and Diagnosis. — If, after separation of a portion of the 
placenta, the blood finds its way between the membranes and the 
decidua, its escape per vaginam, even although in small amount, at 
once attracts attention, and reveals the nature of the accident. It 
is otherwise when we have to do with a case of concealed hemorrhage, 
the diagnosis of which is often a matter of difficulty. Then the blood 
probably at first collects between the uterus and the placenta. Some- 
times marginal separation does not occur, and large blood-clots are 
formed in this situation, and retained there. More often, the margin 
of the placenta separates, and the blood collects between the mem- 
branes and the uterine wall, either towards the cervix, where the 
presenting part of the child may prevent its escape, or near the 
fundus. In the latter case especially, the coagula are apt to cause 
very painful stretching and distension of the uterus. The blood 
may also find its way into the amniotic cavity, but more frequently 
it does not do so; probably, as Goodell has pointed out, because 
"should the os uteri be closed, the membranes, however delicate, 
cannot, other things being equal, rupture any sooner from the 
uterine walls, for the sum of the resistance of the inclosed liquor 
amnii being equally distributed exactly counterbalances the sum of 

1 Amer. Journ. of Obstet., vol. ii. 



HEMORRHAGE BEFORE DELIVERY. 401 

the pressure exerted by the effusion." This point is of some practical 
importance because, after rupture of the membranes, the liquor amnii 
is frequently found untinged with blood, and this might lead us to 
suppose ourselves mistaken in our diagnosis, if this fact were not 
borne in mind. 

Symptoms of Concealed Accidental Hemorrhage. — The most promi- 
nent symptoms in concealed internal hemorrhage are extreme col- 
lapse and exhaustion, for which no adequate cause can be assigned. 
These differ from those of ordinary syncope, with which they might 
be confounded, chiefly in their persistence and severity, and in the 
presence of the symptoms attending severe loss of blood, such as 
coldness and pallor of the surface, great restlessness and anxiety, 
rapid and sighing respiration, yawning, feeble, quick, and compres- 
sible pulse. When there is severe internal, with slight external 
hemorrhage, we may be led to a proper diagnosis by observing that 
the constitutional symptoms are much more severe than the amount 
of external hemorrhage would account for. Uterine pain is gene- 
rally present, of a tearing and stretching character, sometimes mode- 
rate in amount, more often severe, and occasionally amounting to 
intolerable anguish. It is often localized, and it, doubtless, depends 
on the distension of the uterus by the retained coagula. If the dis- 
tension be marked, there may be an irregularity in the form of the 
uterus at the site of sanguineous effusion ; but this will be difficult 
to make out, except in women with thin and unusually lax abdomi- 
nal parietes. A rapid increase in the size of the uterus has been 
described as a sign by Cazeaux and others. It is not very likely 
that this will be appreciable towards the end of utero-gestation, as a 
very large amount of effusion would be necessary to produce it. At 
an earlier period of pregnancy, at or about the fifth month, I made it 
out very distinctly in a case in my own practice. It obviously must 
have occurred to an enormous extent in a case related by Chevalier, 
in which post-mortem Cesarean section was performed under the im- 
pression that the pregnancy had advanced to term, but only a three 
months' foetus was found, imbedded in coagula which distended the 
uterus to the size of a nine months' gestation. 1 Labor pains may be 
entirely absent. If present, they are generally feeble, irregular, and 
inefficient. 

Differential Diagnosis. — The only condition, besides ordinary syn- 
cope, likely to be confounded with this form of hemorrhage, is rup- 
ture of the uterus, to which the intense pain and profound collapse 
induce considerable resemblance. The latter rarety occurs until after 
labor has been some time in progress, and after the escape of the 
liquor amnii ; whereas hemorrhage usually occurs either before labor 
has commenced, or at an early stage. The recession of the presenta- 
tion, and the escape of the foetus into the abdominal cavity, in cases 
of rupture, will farther aid in establishing the diagnosis. 

Prognosis. — The prognosis, when blood escapes externally, is, on 
the whole, not unfavorable. The nature of the case is apparent, and 

J Journ. de Med. Clin, et Pharraac, vol. xxi. p. 363. 



402 LABOR. 

remedial measures are generally adopted sufficiently early to prevent 
serious mischief. It is different with the concealed form, in which 
the mortality is very great. Out of Goodell's 106 cases, no less than 
54 mothers died. This excessive death-rate is, no doubt, partly due to 
the fact that extreme prostration so often occurs before the existence 
of hemorrhage is suspected, and partly to the accident generally hap- 
pening in women of weakly and diseased constitution. The prog- 
nosis to the child is still more grave. Out of 107 children, only 6 
were born alive. The almost certain death of the child may be ex- 
plained by the fact that, when blood collects between the uterus and 
the placenta, the foetal portion of the latter is probably lacerated, 
and the child then also dies from hemorrhage. 

Treatment. — In this, as in all other forms of puerperal hemorrhage, 
the great hemostatic is uterine contraction, and that we must try to 
encourage by all possible means. The first thing to be done, whether 
the hemorrhage be apparent Or concealed, is to rupture the mem- 
branes. If the loss of blood be only slight, this may suffice to con- 
trol it, and the case may then be left to nature. A firm abdominal 
binder should, however, be applied to prevent any risk of blood col- 
lecting internally, as there is nothing to prevent its filling the uterine 
cavity after the membranes are ruptured. Contraction may be 
further advantageously solicited by uterine compression, and by the 
administration of full doses of ergot. If hemorrhage continue, or if 
we have any reason to suspect concealed hemorrhage, the sooner the 
uterus is emptied the better. If the os be sufficiently dilated, the 
best practice will be to turn without further delay, using the bi-polar 
method if possible. If the os be not open enough, a Barnes's bag 
should be introduced, while firm pressure is kept up to prevent 
uterine accumulation. Should the collapsed condition of the patient 
be very marked, the mere shock of the operation might turn the 
scale against her. Under such circumstances it may be better prac- 
tice to delay further procedure until, by the administration of stimu- 
lants, warmth, etc., we have succeeded in producing some amount of 
reaction, keeping up, in the meanwhile, firm pressure on the uterus. 
Should the head be low down in the pelvis, it may be easier to com- 
plete labor by means of the forceps. 



CHAPTER XV. 

HEMORRHAGE AFTER DELIVERY. 



Hemorrhage during, or shortly after, the third stage of labor is 
one of the most trjnng and dangerous accidents connected with partu- 
rition. Its sudden and unexpected occurrence just after the labor 
appears to be happily terminated, and its alarming effect on the 



HEMORRHAGE AFTER DELIVERY. -103 

patient, who is often placed in the utmost danger in a few moments, 
tax the presence of mind and the resources of the practitioner to the 
utmost, and render it an imperative duty on every one who practises 
midwifery to make himself thoroughly acquainted with its causes, 
and preventive and curative treatment. There is no emergency in 
obstetrics which leaves less time for reflection and consultation, and 
the life of the patient will often depend on the prompt and imme- 
diate action of the medical attendant. 

Frequency of Post-partum Hemorrhage. — Post-partum hemorrhage 
is one of the most frequent complications of delivery. I do not 
know of any statistics which enable us to judge with accuracy of its 
frequency, but I believe it to be an unquestionable fact that, espe- 
cially in the upper ranks of society, it is very common indeed. This 
is probably due to the effects of civilization, and to the mode of life 
of patients of that class, whose whole surroundings tend to produce 
a lax habit of body which favors uterine inertia, the principal cause 
of post-partum hemorrhage. 

Generally a Preventable Accident. — Fortunately, it is, to a great 
extent, a preventable accident. I believe this fact canno t be too 
strongly impressed on the practitioner. If the third stage of labor 
be properly conducted, if every case be treated, as every case ought 
to be, as if hemorrhage were impending, it would be much more in- 
frequent than it is. It is a curious fact that post-partum hemorrhage 
is much more common in the practice of some medical men than in 
that of others ; the reason being, that those who meet with it often 
are careless in their management of their patients immediately after 
the birth of the child. That is just the time when the assistance of 
a properly qualified practitioner is of value, much more so than 
before the second stage of labor is concluded ; hence when I hear 
that a medical man is constantly meeting with severe post-partum 
hemorrhage, I hold myself justified ipso facto in inferring that he 
does not know, or does not practise, the proper mode of managing 
the third stage of labor. 

Causes and Nature^s Method of Controlling Hemorrhage after De- 
livery. — The placenta, as we have seen, is separated hj the last pains, 
and the blood, which in greater or less quantity accompanies the 
foetus, probably comes from the utero-placental vessels which are 
then lacerated. Almost immediately afterwards the uterus contracts 
firmly, and, in a typical labor, assumes the hard cricket-ball form 
which is so comforting to the accoucheur to feel. The result is the 
compression of all the vascular trunks which ramify in its walls, both 
arteries and veins, and thus the flow of blood through them is pre- 
vented. By referring to what has been said as to the anatomy of the 
muscular fibres of the gravid uterus, especially at the placental site 
(p. 52), it will be seen how admirably they are adapted for this 
purpose. The arrangement of the vessels themselves favors the 
j haemostatic action of uterine contraction. The large venous sinuses 
are placed in layers, one above the other, in the thickness of the 
uterine walls, and they anastomose freely. When the superimposed 
layers communicate with those immediately below them, the junc- 



404 LABOR. 

tion is by a falciform or semilunar opening in the floor of the vessel 
nearest the external surface of the uterus. Within the margins of 
this aperture there are muscular fibres, the contraction of which 
probably tends to prevent retrogression of blood from one layer of 
vessels into the other. The venous sinuses themselves are of a flat- 
tened form, and they are intimately attached to the muscular tissues. 
It is obvious, then, that these anatomical arrangements are emi- 
nently adapted to facilitate the closure of the vessels. They are, 
however, large, and are destitute of valves ; and, if contraction be 
absent, or if it be partial and irregular, it is equally easy to under- 
stand why blood should pour forth in the appalling amount which is 
sometimes observed. 

Importance of Tonic Uterine Contraction. — If uterine action be firm, 
regular, and continuous, the vessels must be sealed up, and hemor- 
rhage effectually prevented. This fact has been doubted by many 
authorities. Grooch was the first to describe what he called " a pecu- 
liar form of hemorrhage" accompanying a contracted womb, and 
similar observations have been made by other writers, such as 
Velpeau, Bigby, and Grendrin. Simpson says, on this point, that 
strong uterine contractions " are not probably so essential a part in 
the mechanism of the prevention of hemorrhage from the open ori- 
fices of the uterine veins as we might a priori suppose." 1 With re- 
gard to Gooch's cases, it has been pointed out that his own description 
proves that, however firmly the uterus may have contracted imme- 
diately after the expulsion of the child, it must have subsequently 
relaxed, for he passed his hand into it to remove retained clots, a 
manoeuvre which he could not have practised had tonic contraction 
been present. Barnes suggests that in some of these cases the 
hemorrhage came from a laceration of the cervix. Of course, blood 
may readily escape from a mechanical injury of this kind, although 
the uterus itself be in a satisfactory state of contraction, and the 
possibility of this occurrence should always be borne in mind. 

Although, then, Ave may admit that post-partum hemorrhage is 
incompatible with persistent contraction of the uterus, it by no means 
follows that the converse is true. On the contrary, it is not uncom- 
mon to meet with cases in which the uterus is large and apparently 
quite flaccid, and in which there is no loss of blood. Alternate re- 
laxation and contraction of the uterus after delivery are also of con- 
stant occurrence, and yet hemorrhage, during the relaxation, does 
not take place. The explanation no doubt is that, immediately 
after the birth of the child, there was sufficient contraction to pre- 
vent hemorrhage, and that, during its continuance, coagula formed 
in the mouths of the uterine sinuses, by which they were suffi- 
ciently occluded to prevent any loss when subsequent relaxation 
occurred. 

In all probability both uterine contraction and thrombosis are in 
operation in ordinary cases ; and we shall presently see that all the 

1 Selected Obstetric Works, p. 234. 



HEMORRHAGE AFTER DELIVERY. 405 

means employed in the treatment of post-partum hemorrhage act by 
producing one or other of them. 

Secondary Causes of Hemorrhage. — Uterine inertia after labor, then, 
may be regarded as the one great primary cause of post-partum. 
hemorrhage; but there are various secondary causes which tend to 
produce it, one of the most frequent of which is exhaustion follow- 
ing a protracted labor. The uterus gets worn out by its efforts, and 
when the foetus is expelled, it remains in a relaxed state, and hemor- 
rhage results. Over-distension of the uterus acts in the same way. 
Hence hemorrhage is very frequently met with when there has been 
an excessive amount of liquor amnii, or in multiple pregnancies. 
One of the worst cases I ever met with was after the birth of triplets, 
the uterus having been of an enormous size. Rapid emptying of the 
uterus, during which there has not been sufficient time for complete 
separation of the placenta, often tends to the same result. This is 
the reason why hemorrhage so frequently follows forceps delivery, 
especially if the operation have been unduly hurried ; and it is one 
of the chief dangers in what are termed " precipitate labors." The 
general condition of the patient may also strongly predispose to it. 
Thus it is more often met with in women who have borne families, 
especially if they be weakly in constitution, comparatively seldom 
in primiparse ; and for the same reason that after-pains are most 
common in the former, namely that the uterus, weakened by frequent 
child-bearing, contracts inefficiently. The experience of practitioners 
in the tropics shows that European women, debilitated by the relax- 
ing effects of warm climates, are peculiarly prone to it, and it forms 
one of the chief dangers of childbirth amongst the English ladies in 
India. 

Irregular Uterine Contraction. — Another important cause of post- 
partum hemorrhage is partial and irregular contraction of the uterus. 
Part of the muscular tissue is firmly contracted, while another part 
is relaxed, and the latter very often the placental site. This has 
been especially dwelt on by Simpson. He says, "the morbid con- 
dition which is most frequently and earliest seen in connection with 
post-partum hemorrhage, is a state of irregularity and want of equa- 
bility in the contractile action of different parts of the uterus — and, 
it may be in different planes of the muscular fibres — as marked by 
one or more points in the organ feeling hard and contracted, at the 
same time that other portions of the parietes are soft and relaxed." 

Hour-glass Contraction. — One peculiar variety, which has been 
much dwelt on by writers, and is a prominent bugbear to obstetri- 
cians, is the so-called " hour-glass contraction." This in reality seems 
to depend on spasmodic contraction of the internal os uteri, by means 
of which the placenta becomes encysted in the upper portion of the 
uterus, which is relaxed. On introducing the hand, it first passes 
through the lax cervical canal, until it comes to the closed internal 
os, with the umbilical cord passing through it, which has generally 
been supposed to be a circular contraction of a portion of the body 
of the uterus. 

[The late Prof. Meigs was of the opinion that an encysted placenta 



406 



LABOR. 



was always an adherent one, and that the local inertia was the forced 
effect of the adhesion, preventing mechanically the contraction of the 
uterus over the utero-placental space. This was also the opinion of 
Kamsbotham, from whose work the following plates are taken. He 
had never seen a true hour-glass constriction, such as the right hand 
drawing. Miller claims to have met with the condition on several oc- 
casions. — Ed.] Encystment of the placenta, however, although more 
rarely, unquestionably takes place in a portion only of the body of 
the uterus (Fig. 138). Then apparently the placental site remains 

Fig. 138. 





Irregular Contraction of the Uterus, with Encystment of the Placenta. 

more or less paralyzed, with the placenta still attached, while the 
remainder of the body of the uterus contracts firmly, and thus encyst- 
ment is produced. 

Causes of Irregular Contractions. — These irregular contractions of 
the uterus are by no means so common as our older authors supposed. 
"When they do occur I believe them almost invariably to depend on 
defective management of the third stage of labor. " The most fre- 
quent cause," says Rigby, 1 "is from over anxiety to remove the 
placenta ; the cord is frequently pulled at, and at length the os uteri 
is excited to contract." While this is being done, no attempts are 
probably being made to excite the fundus to proper action, and, 
therefore, the hour-glass contraction is established. Duncan says of 
this condition : " Hour-glass contraction cannot exist unless the parts 
above the contraction are in a state of inertia ; were the higher 
parts of the uterus even in moderate action, the hour-glass contrac- 
tion would soon be overcome." 2 If placental expression were always 
employed, if it were the rule to effect the expulsion of the placenta 
by a vis a teryo, instead of extracting by a vis d fronte, I feel con- 
fident that these irregular and spasmodic contractions — of the influ- 
ence of which in producing hemorrhage there can be no question — 
would rarely, if ever, be met with. Tt is to be observed that even 



1 Rigby' s Midwifery, p. 225. 



Researches in Obstetrics, p. 389. 



HEMORRHAGE AFTER DELIVERY. 407 

in these cases, it is not because the uterus is in a state of partial con- 
traction, but because it is in a state of partial relaxation, that hemor- 
rhage ensues. 

Placental Adhesions. — Adhesions of the placenta to the uterine 
parietes may cause hemorrhage, especially if they be partial, and 
the remainder of the placentae be detached. The frequency of these 
has been over-estimated. Many cases believed to be examples of 
adherent placentas are, in reality, only cases of placentae retained 
from uterine inertia. The experience of all who see much midwifery 
will probably corroborate the observation of Brann, that "abnormal 
adhesion and hour-glass contraction are more frequently encountered 
in the experience of the young practitioner, and they diminish in 
frequency in direct ratio to increasing years." 1 The cause of adhe- 
sion is often obscure, but it most probably results from a morbid 
state of the decidua, which is produced by antecedent disease of the 
uterine mucous membrane; then the adhesion is apt to recur in sub- 
sequent pregnancies. The decidua is altered and thickened, and 
patches of calcareous and fibrous degeneration may be often found 
on the attached surface of the placenta. Most frequently the placenta 
is only partially adherent ; patches of it remain firmly attached to 
the uterus, while the rest is separated ; hence the uterine walls re- 
main relaxed, and hemorrhage frequently follows. The diagnosis 
and management of these very troublesome cases will be found de- 
scribed under the head of treatment (p. 411). 

Constitutional Predisposition to Flooding. — Finally I think it must 
be admitted that there are some women who really merit the appel- 
lation of "Flooclers," which has been applied to them, and who, clo 
what we may, have the most extraordinary tendency to hemorrhage 
after delivery. I do not think that these cases, however, are by any 
means so common as some have supposed. 2 I have attended several 
patients who have nearly lost their lives from post-partum hemor- 
rhage in former labors, some who have suffered from it in every pre- 
ceding confinement, and I have only met with two cases in which 
the assiduous use of preventive treatment failed to avert it. In these 
(one of which I have elsewhere published in detail 3 ), in spite of all 
my efforts, I could not succeed in keeping up uterine contraction, 
and the patients would certainly have lost their lives were it not for 
the means which modern improvements have fortunately placed at 
our disposal for producing thrombosis in the mouths of the bleeding 
vessels. The nature of these rare cases requires further investiga- 
tion ; possibly they may, to some extent, be the subjects of the so- 
called hemorrhagic diathes 

Signs and Symptoms. — The loss of blood may commence immedi- 
ately after the birth of the child, before the expulsion of the placenta, 
or not until some time afterwards, when the contracted uterus has 
again relaxed. It may commence gradually, or suddenly; in the 
latter case, it may begin with a gush, and in the worst form the bed- 

1 Braun's Lectures, 1869. [ 2 See remarks on quinia, p, 330. — Ed.] 

3 Obst. Journ., vol. i. 



408 LABOR. 

clothes, the bed, and even the floor, are deluged with the blood which, 
it is no exaggeration to say, is pouring from the patient. If now the 
hand be placed on the abdomen, we shall miss the hard round ball 
of the contracted uterus, which will be found soft and flabby, or we 
may even be unable to make out its contour at all. If the hemor- 
rhage be slight, or if we succeed in controlling it at once, no serious 
consequences follow ; but if it be excessive, or if we fail to check it, 
the gravest results ensue. 

Exhaustion in Extreme Cases. — There are few sights more appal- 
ling to witness than one of the worst cases of post-partum hemorrhage. 
The pulse becomes rapidly affected, and may be reduced to a mere 
thread, or it may become entirely imperceptible. Syncope often 
comes on, not in itself always an unfavorable occurrence, as it tends 
to promote thrombosis in the venous sinuses. Or, short of actual 
syncope, there may be a feeling of intense debility and faintness. 
Extreme restlessness soon supervenes, the patient throws herself 
about the bed, tossing her arms wildly above her head ; respiration 
becomes gasping and sighing, the "besoin de respirer" is acutely felt, 
and the patient cries out for more air ; the skin becomes deadly cold, 
and covered with profuse perspiration ; if the hemorrhage continue 
unchecked, we next may have complete loss of vision, jactitation, 
convulsions, and death. 

Formidable as such symptoms are, it is satisfactory to know that 
recovery often takes place, even when the powers of life seem reduced 
to the lowest ebb. If we can check the hemorrhage while there is 
still some power of reaction left, however slight, we may not unrea- 
sonably hope for eventual recovery. The constitution, however, may 
have received a severe shock, and it may be months, or even years, 
before the patient recovers from the effects of only a few minutes' 
hemorrhage. A death-like pallor frequently follows these excessive 
losses, and the patient often remains blanched and exsanguine for a 
long time. 

Preventive Treatment. — The preventive treatment of post-partum 
hemorrhage should be carefully practised in every case of labor, 
however normal. If the practitioner make a habit of never remov- 
ing his hand from the uterus after the birth of the child until the 
placenta is expelled, and of keeping up continuous uterine contrac- 
tion for at least half an hour after delivery is completed, not neces- 
sarily by friction on the fundus, but by simply grasping the contracted 
womb with the palm of the hand and preventing its undue relaxation, 
cases of post-partum flooding will seldom be met with. As a rule 
we should, I think, not apply the binder until at least that time has 
elapsed. The binder is an effective means of keeping up, but not of 
producing, contraction, and it should never be trusted to for the latter 
purpose. If it be put on too soon, the uterus may relax under it, 
and become filled with clots without the practitioner knowing any- 
thing about it; whereas this cannot possibly take place as long as 
the uterine globe is held in the hollow of the hand. I have seen 
more than one serious case of concealed hemorrhage result from the 
too common habit of putting on the binder immediately after the 



HEMORRHAGE AFTER DELIVERY. 409 

removal of the placenta. I believe also, as I have formerly said, 
that it is thoroughly good practice to administer a full dose of the 
liquid extract of ergot in all cases after the placenta has been ex- 
pelled, to insure persistent contraction, and to lessen the chance of 
blood-clots being retained in utero. 

These are the precautions which should be used in all cases alike; 
but when we have reason to fear the occurrence of hemorrhage, from 
the history of previous labors or other cause, special care should 
be taken. The ergot should be given, and preferably in the form of 
the subcutaneous injection of ergotine, before the birth of the child, 
when the presentation is so far advanced that we estimate that labor 
will be concluded in from ten to twenty minutes, as we can hardly 
expect the drug to produce any effect in less time. Particular atten- 
tion, moreover, should then be paid to the state of the uterus. Every 
means should be taken to insure regular and strong contraction, and 
it is advisable to rupture the membranes early, as soon as the os is 
dilated or dilatable, to insure stronger uterine action. If any tend- 
ency to relaxation occur after delivery, a piece of ice should be 
passed into the vagina, or into the uterus. Should coagula collect 
in the uterus, they may be readily expelled by firm pressure on the 
fundus, and the finger should be passed occasionally up to the cervix, 
and any which are felt there should be gently picked away. 

We should be specially on our guard in all cases in which the 
pulse does not fall after delivery. If it beat at 100 or more some 
ten minutes or a quarter of an hour after the birth of the child, 
hemorrhage not unfrequently follows; and, hence, it is a good prac- 
tical rule, which may save much trouble, that a patient should never 
be left unless the pulse has fallen to its natural standard. 

Curative Treatment. — As there are only two means which nature 
adopts in the prevention of post-partum hemorrhage, so the remedial 
measures also may be divided into two classes. 1. Those which act 
by the production of uterine contraction. 2. Those which act by 
producing thrombosis in the vessels. Of these the first are the most 
commonly used ; and it is only in the worst cases, in which they have 
been assiduously tried and have failed, that we resort to those coming 
under the second heading. 

Uterine Pressure. — The patient should be placed on her back, in 
which position we can more readily command the uterus, as well as 
attend to her general state. If the uterus be found relaxed and fall 
of clots, by firmly grasping it in the hand contraction may be evoked, 
its contents expelled, and further hemorrhage at once arrested. Should 

I this fortunately be the case, we must keep up contraction by gently 
kneading the uterus, until we are satisfied that undue relaxation will 

, not recur. The powerful influence of friction in promoting contrac- 
tion cannot be doubted, and nothing will replace it; no doubt it is 
fatiguing, but as long as it is effectual it must be kept up. No 

\ roughness should be used, as we might produce subsequent injury, 
but it is quite possible to use considerable pressure without any 

' violence. 

Another method of applying uterine pressure has been strongly 
27 



410 LABOR. 

advocated by Dr. Hamilton, of Falkirk, and it may be serviceable 
where there is a constant draining from the uterus, and a capacious 
pelvis. It consists in passing the fingers of the right hand high up 
in the posterior cul de sac of the vagina, so as to reach the posterior 
surface of the uterus, while counter-pressure is exercised by the left 
hand through the abdomen. The anterior and posterior walls of the 
uterus are thus closely pressed together. 

Administration of Ergot. — During the time that pressure is being 
applied, attention can be paid to general treatment ; and in giving 
his directions to the bystanders the practitioner should be calm and 
collected, avoiding all hurry and excitement. A full dose of ergot 
should be administered, and if one have already been given, it should 
be repeated. We cannot, however, look upon ergot as anything but a 
useful accessory, and it is one which requires considerable time to 
operate. The hypodermic use of ergotine offers the double advan- 
tage, in severe cases, of acting with greater power, and much more 
rapidly than the usual method of administration. It should, there- 
fore, always be used in preference. 

Stimulants. — The sudden flow will probably have produced ex- 
haustion and a tendency to syncope, and the administration of stimu- 
lants will be necessary. The amount must be regulated by the state 
of the pulse, and the degree of exhaustion. There is no more ab- 
surd mistake, however, than implicitly relying on the brandy bottle 
to check post-partum hemorrhage. In the worst cases absorption is 
in abeyance, and brandy may be poured down in abundance, the prac- 
titioner believing that he is rousing his patient, while he is, in fact, 
merely filling the stomach with a quantity of fluid, which is eventu- 
ally thrown up unaltered. I have more than once seen symptoms, 
produced from the over-free use of brandy in slight floodings, which 
were certainly not those of hemorrhage. I remember on one occa- 
sion being summoned by a practitioner, with a view to transfusion, 
to a patient who was said to be insensible and collapsed from hemor- 
rhage. I found her, indeed, unconscious; but with a flushed face, a 
bounding pulse, a firmly contracted uterus, and deep stertorous 
breathing. On inquiry I ascertained that she had taken an enor- 
mous quantity of brandy, which had brought on the coma of pro- 
found intoxication, while the hemorrhage had obviously never been 
excessive. 

Hypodermic Injection of Ether. — The hypodermic injection of sul- 
phuric ether has been recommended as a powerful stimulant in 
cases in which exhaustion is very great. A fluidrachm may be in- 
jected, and the remedy is Avorthy of trial, when the tendency to syn- 
cope is extreme. 

Fresh Air, etc. — The windows should be thrown widely open, to 
allow a current of fresh cold air to circulate freely through the room. 
The pillows should be removed, the head kept low, and the patient 
should be assiduously fanned. 

Emptying of Uterus. — If bleeding continue, or if it commence be- 
fore the placenta is expelled, the hand should be carefully and gently 
passed into the uterus, and its cavity cleared of its contents. The 



HEMORRHAGE AFTER DELIVERY. 411 

mere presence of the hand within the uterus is a powerful incitor of 
uterine action. When the placenta is retained it is the more essen- 
tial, as the hemorrhage cannot possibly be checked as long as the 
uterus is distended by it. During the operation the uterus should 
be supported by the left hand externally, and, by using the two 
hands in concert, the chances of injuring the textures are greatly 
lessened. 

Treatment of Hour-glass Contraction. — If the so-called "hour glass 
contraction " be present, or if the placenta be morbidly adherent, the 
operation will be more difficult, and will require much judgment and 
care. The spasmodic contraction of the inner os in the former case 
may generally be overcome by gentle and continuous pressure of the 
fingers passed within the contraction, while the uterus is supported 
from without. By this means, too, further hemorrhage can in most 
cases be controlled, until the spasm is sufficiently relaxed to admit of 
the passage of the hand. 

Signs of Adherent Placenta. — There are no very reliable signs to 
indicate morbid adhesion of the placenta, previous to the introduc- 
tion of the hand. The following are the symptoms as laid down by 
Barnes, any of which might, however, accompany non-detachment of 
the placenta, unaccompanied by adhesion : " You may suspect mor- 
bid adhesion, if there have been unusual difficulty in removing the 
placenta in previous labors ; if, during the third stage, the uterus 
contracts at intervals firmly, each contraction being accompanied by 
blood, and yet, on following up the cord, you feel the placenta in 
utero ; if on pulling on the cord, two fingers being pressed into the 
placenta at the root, you feel the placenta and uterus descend in one 
mass, a sense of dragging pain being elicited ; if, during a pain the 
uterine tumor does not present a globular form, but be more promi- 
nent than usual at the place of placental attachment." 1 

Treatment of Adherent Placenta. — The artificial removal of an ad- 
herent placenta is always a delicate and anxious operation, which, 
however carefully performed, must of necessity expose the patient 
to the risk of injury to the uterine structures, and of leaving behind 
portions of placental tissue, which may give rise to secondary hemor- 
rhage, or septicaemia. The cord will guide the hand to the site of 
attachment, and the fingers must be very gently insinuated between 
the lower edge of the placenta and the uterine wall ; or, if a portion 
be already detached, we may commence to peel off the remainder at 
that spot. Supporting the uterus externally, we carefully pick off as 
much as possible, proceeding with the greatest caution, as it is by no 
means easy to distinguish between the placenta and the uterus. At 
the best it is far from easy to remove all, and it is wiser to separate 
only what we readily can, than to make too protracted efforts at com- 
plete detachment. When it is found to be impossible to detach and 
remove the whole, or a great part of the placenta, we cannot but 
look upon the further progress of the case with considerable anxiety. 
The retained portions may be, ere long, spontaneously detached and 

1 Obstetric Operations, p. 440. 



412 LABOR. 

expelled, or they may decompose and give rise to fetid discharge 
and septic infection. Such cases must be treated by antiseptic intra- 
uterine injections, so as to lessen the risk of absorption as much as 
possible ; but until the retained masses have been expelled, and the 
discharge has ceased, the patient must be considered to be in consider- 
able danger. In a few rare cases, there is reason to believe that 
considerable masses of retained placental tissue have been entirely 
absorbed. It is difficult to understand so strange a phenomenon, 
but several well-authenticated cases are recorded, in which there 
seems no reason to doubt that the retained placenta was removed in 
this way. 1 

Excitement of Reflex Action by Cold, etc. — Various means are used 
for exciting uterine contraction by reflex stimulation. Amongst the 
most important of these is cold. In patients who are not too ex- 
hausted to respond to the stimulus applied, it is of extreme value. 
But, to be of use, it should be used intermittently, and not continu- 
ously. Pouring a stream of cold water from a height on the abdomen 
is a not uncommon, but bad, practice, as it deluges the patient and 
the bedding in water, which may afterwards act injuriously. Flap- 
ping the lower part of the abdomen with a wet towel is less objec- 
tionable. Ice can generally be obtained, and a piece should be in- 
troduced into the uterus. This is a very powerful haemostatic, and 
often excites strong action when other means fail. I constantly em- 
ploy it, and have never seen any bad results follow. A large piece 
of ice may also be held over the fundus, and removed, and re-applied 
from time to time. Iced water may be injected into the rectum. A 
very powerful remedy is washing out the uterine cavity with a 
stream of cold water, by means of the vaginal pipe of a Higginson's 
syringe carried up to the fundus. Another means of applying cold, 
said to be very effectual, is the application of the ether spray, such as 
is used for producing local anaesthesia, over the lower part of the 
abdomen. 2 All these remedies, however, depend for their good re- 
sults on the fact of the patient being in a condition to respond to 
stimulus ; and their prolonged use, if they fail to excite contraction 
rapidly, will certainly prove injurious. Rigby used to look upon the 
application of the child to the breast as one of the most certain in- 
citors of uterine action. It may be of service, after the hemor- 
rhage has been checked, in keeping up tonic contraction, and should 
therefore not be omitted; but we certainly cannot waste time in in- 
ducing the child to suck in the face of the actual emergency. 

Intra-uterine Injections of Warm. Water. — Of late, intra- uterine in- 
jections of warm water, at a temperature of from 110° to 120°, have 
been highly recommended as a powerful means of arresting post- 
partum hemorrhage, often proving effectual when all other treatment 
has failed. The number of published cases in which it has proved 
of great value is now considerable. The present master of the 

1 See an interesting paper by Dr. Thrush on " Retention of the Placenta in Labor 
at Term." Am. Journ. of Obstet., July, 1877. 

2 Griffiths, Practitioner, March, 1877. 



HEMORRHAGE AFTER DELIVERY. 413 

Rotunda, Dr. Lombe Atthill, lias recorded 16 cases 1 in which it 
checked hemorrhage at once, in many of which ergot, ice, and other 
means had failed. He speaks of it as especially useful in those 
troublesome cases in which the uterus alternately relaxes and 
hardens, and resists all our efforts to produce permanent contraction. 
My own experience of this treatment is too limited to justify my 
giving a decided opinion on its merits; but I have tried it in two or 
three cases, and in them the result certainly exceeded my expecta- 
tions. I think it cannot be doubted that we have in these warm 
irrigations a valuable addition to our methods of treating uterine 
hemorrhage. 

State of the Bladder. — The late Dr. Earle pointed out 2 that a dis- 
tended bladder often prevents contraction, and to avoid the possi- 
bility of this the catheter should be passed. 

Plugging the Vagina. — Plugging of the vagina has often been 
used. It is only necessary to mention it for the purpose of insisting 
on its absolute inapplicability in all cases of post-partum hemorrhage ; 
the only effect it could have would be to prevent the escape of blood 
externally, which might then collect to any extent in the cavity of 
the uterus. 

Compression of the abdominal aorta is highly thought of by many 
continental authorities, but is little known or practised in this 
country. It has been objected to by some on the theoretical ground 
that the hemorrhage is chiefly venous, and not arterial, and that it 
would only favor the reflux of venous blood into the vena cava. 
Cazeaux points out that, on account of the close anatomical relations 
between the aorta and the vena cava, it is hardly possible to compress 
one vessel without the other. The backward flow of blood, therefore, 
through the vena cava may also be thus arrested. There is strong 
evidence in favor of the occasional utility of compression. Its chief 
recommendation is, that it can be practised immediately, and by an 
assistant who can be shown how to apply the pressure. It is most 
likely to prove useful in sudden and severe hemorrhage, and, if it 
only control the loss for a few moments, it gives us time to applv 
other methods of treatment. As a temporary expedient, therefore, 
it should be borne in mind, and adopted when necessary. It has 
the great advantage of supplementing, without superseding, other 
and more radical plans of treatment. The pressure is very easily 
applied, on account of the lax state of the abdominal walls. The 
artery can readily be felt pulsating above the fundus uteri, and can 
be compressed against the vertebrae by three or four fingers applied 
lengthways. Baudelocque, who was a strong advocate of this pro- 
cedure, states that he has, on several occasions, controlled an other- 
wise intractable hemorrhage in this way, and that he, on one occasion, 
kept up compression for four consecutive hours. Cazeaux believes 
that compression of the aorta may have a further advantageous effect 
in retaining the mass of the blood in the upper part of the body, and 
thus lessening the tendency to syncope and collapse. If an aortic 

1 Lancet, February 9, 1878. 2 Earle' s Flooding after Delivery, p. 1G3. 



414 LABOR. 

tourniquet, such as is used for compressing the vessel in cases of 
aneurism, could be obtained, it might be used with advantage in 
serious cases. 

Bandaging of the Extremities. — When the hemorrhage has been 
excessive, and there is profound exhaustion, firm bandaging of the 
extremities, by preference with Esmarch's elastic bandages if they 
can be obtained, may be advantageously adopted, with the view of 
retaining the blood as much as possible in the trunk, and thus lessen- 
ing the tendency to syncope. As a temporary expedient in the 
worst class of cases it may occasionally prove of service. 

Injection of Styptics. — Supposing these means fail, and the uterus 
obstinately refuses to contract in spite of all our efforts — and, do 
what we may, cases of this kind will occur — the only other agent at 
our command is the application of a powerful styptic to the bleeding 
surface to produce thrombosis in the vessels. "The latter," says Dr. 
Ferguson, 1 alluding to this means of arresting hemorrhage, "appears 
to be the sole means of safety in those cases of intense flooding in 
which the uterus flaps about the hand like a wet towel. Incapable 
of contraction for hours, yet ceasing to ooze out a drop of blood, 
there is nothing apparently between life and death but a few soft 
coagula plugging up the sinuses." These form but a frail barrier 
indeed, but the experience of all who have used the injection of a 
solution of perchloride of iron in such cases, proves that they are 
thoroughly effectual, and its introduction into practice is one of the 
greatest improvements in modern midwifery. Although this method 
of treating these obstinate cases is not new, since it was practised 
long ago in Germany, its adoption in this country is unquestionably 
due to the energetic recommendation of Dr. Barnes. Although the 
dangers of the practice have been strongly insisted on, and with a 
degree of acrimony that is to be regretted, I know of only one pub- 
lished case in which its use has been followed by any evil effects. 
Its extraordinary power, however, of instantly checking the most 
formidable hemorrhage, has been demonstrated by the unanimous 
testimony of all who have tried it. As it is not proposed by any one 
that this means of treatment should be employed until all ordinary 
methods of evoking contraction have failed, and as, in cases of this 
kind, the lives of the patients are of necessity imperilled, we should 
be fully justified in adopting it, even if its possible injurious effects 
had been much more certainly proved. It is surely at any time 
justifiable to avoid a great and pressing peril by running a possible 
chance of a less one. Whenever, therefore, we have tried the plans 
above indicated in vain, no time should be lost in resorting to this 
expedient. No practitioner should attend a case of midwifery with- 
out having the necessary styptic with him. The best and most 
easily obtainable form of using the remedy is the " liquor ferri per- 
chloricli fortior" of the London Pharmacopoeia, which should be 
diluted for use with six times its bulk of water. This is certainly 
better than a weaker solution. The vaginal pipe of a Higginson's 

1 Preface to Gooch On Diseases of Women, p. xlii. 



HEMORRHAGE AFTER DELIVERY. 415 

svringe, through which the solution has once or twice been pumped 
to exclude the air, is guided by the hand to the fundus uteri, and 
the fluid injected gently over the uterine surface. The loose and 
flabby mucous membrane is instantaneously felt to pucker up, all 
the blood with which the fluid comes in contact is coagulated, and 
the hemorrhage is immediately arrested. I think it is of importance 
to make sure that the uterus and vagina are emptied of clots before 
injection. In the only case in which I have seen any bad symptoms 
follow, this precaution had been neglected. The iron hardened all 
the coagula, which remained in utero, and septicaemia supervened ; 
which, however, disappeared after the clots had been broken up and 
washed away by intra-uterine antiseptic injections. After we have 
resorted to this treatment, all further pressure on the uterus should 
be stopped. \Ye must remember that we have now abandoned con- 
traction as an haemostatic, and are trusting to thrombosis, and that 
pressure might detach and lessen the coagula which are preventing 
the escape of blood. 

Other local astringents may be eventually found to be of use. 
Tincture of matico possibly might be serviceable, although I am not 
aware that it has beeu tried. Dupierris has advocated tincture of 
iodine, and has recorded 24 cases in which he employed it, in all 
without accident and with a successful issue. But nothing seems 
likely to act so immediately, or so effectually, as the perchloride of 
iron. 

Hemorrhage from Laceration of Maternal Structures. — A word 
mav here be said as to the occasional dependence of hemorrhage 
after delivery on laceration of the cervix, or other injury to the 
maternal soft parts. Duncan has narrated a case in which the bleed- 
ing came from a ruptured perineum. If hemorrhage continue after 
the uterus is permanently contracted, a careful examination should 
be made to ascertain if any such injury exist. Most generally the 
source of bleeding is the cervix, and the flow can be readily arrested 
by swabbing the injured textures with a sponge saturated in a solu- 
tion of the perchloride. 

Secondary Treatment. — The secondary treatment of post-partum 
hemorrhage is of importance. When reaction commences, a train 
of distressing symptoms often show themselves, such as intense and 
throbbing headache, great intolerance of light and sound, and general 
nervous prostration ; and, when these have passed away, we have to 
deal with the more chronic effects of profuse loss of blood. ISTothing 
is so valuable in relieving these symptoms as opium. It is the best 
restorative that can be employed, but it must be administered in 
larger doses than usual. Thirty to forty drops of Battley's solution 
should be given by the mouth, or in an enema. At the same time 
the patient should be kept perfectly still and quiet, in a darkened 
room, and the visits of anxious friends strictly forbidden. Strong- 
beef essence, or gravy soup, milk, or eggs beat up with milk, and 
similar easily absorbed articles of diet, should be given frequently, 
and in small quanties at a time. Stimulants will be required accord- 
ing to the state of the patient, such as warm brandy and water, port 



416 LABOR. 

wine, etc. Rest in bed should be insisted on, and continued much. 
beyond the usual time. Eventually the remedies which act by pro- 
moting the formation of blood, such as the various preparations of 
iron, will be found useful, and may be required for a length of time. 

Transfusion. — Under the head of transfusion I have separately 
treated the application of that last resource in those desperate cases 
in which the loss of blood has been so excessive as to leave no other 
hope. 

Secondary Post-partum Hemorrhage. — In the majority of cases, if 
a few hours have elapsed after delivery without hemorrhage, we 
may consider the patient safe from the accident. It is by no means 
very rare, however, to meet with even profuse losses of blood coming 
on in the course of convalescence, at a time varying from a few hours, 
or days, up to several weeks after delivery. These cases are described 
as examples of " secondary hemorrhage" and they have not received 
at all an adequate amount of attention from obstetric writers, inas- 
much as they often give rise to very serious, and even fatal, results, 
and are always somewhat obscure in their etiology, and difficult to 
treat. We owe almost all our knowledge of this condition to an 
excellent paper by Dr. McClintock, of Dublin, who has collected 
characteristic examples from the writings of various authors, and 
accurately described the causes which are most apt to produce it. 

Profuse Lochial Discharge. — We must, in the first place, distin- 
guish between true secondary hemorrhage and profuse lochial dis- 
charge, continued for a longer time than usual. The latter is not a 
very uncommon occurrence, and is generally met with in cases in 
which involution of the uterus has been checked; as by too early 
exertion, general debility, and the like. The amount of the lochial 
discharge varies in different women. In some patients it habitually 
continues during the whole puerperal month, and even longer, but 
not to an extent which justifies us in including it under the head of 
hemorrhage. In such cases prolonged rest, avoidance of the erect 
posture, occasional small doses of ergot, and, it may be, after the 
lapse of some weeks, astringent injections of oak bark, or alum, will 
be all that is necessary in the way of treatment. 

True secondary hemorrhage is often sudden in its appearance and 
serious in its effects. McClintock mentions 6 fatal cases, and Mr. 
Bassett, of Birmingham, 1 has recorded 13 examples which came 
under his own observation, 2 of which ended fatally. 

The Causes are either Constitutional or Local. — The causes may be 
either constitutional, or some local condition of the uterus itself. 

Among the former are such as produce a disturbance of the vas- 
cular system of the body generally, or of the uterine vessels in 
particular. The state of the uterine sinuses, and the slight barrier 
which the thrombi formed in them offer to the escape of blood, readily 
explain the fact of any sudden vascular congestion producing hemor- 
rhage. Thus mental emotions, the sudden assumption of the erect 
posture, any undue exertion, the incautious use of stimulants, a 

1 Brit. Med. Jour., 1872. 



HEMORRHAGE AFTER DELIVERY. 417 

loaded condition of the bowels, or sexual intercourse shortly after 
delivery, may act in this way. McClintock records the case of a 
lady in whom very profuse hemorrhage occurred on the twelfth day 
after labor, when sitting up for the first time. Feeling faint after 
suckling, the nurse gave her some brandy, whereupon a gush of 
blood ensued, "deluging all the bed-clothes and penetrating through 
the mattress so as to form a pool on the floor." Here the erect posi- 
tion, the exquisite pain caused by nursing, and the stimulating drink, 
all concurred to excite the hemorrhage. In another instance the 
flooding was traced to excitement produced by the sudden return of 
an old lover on the eighth day after labor. Moreau especially dwells 
on the influence of local congestion produced by a loaded condition 
of the rectum. Constitutional affections producing general debility, 
and an impoverished state of the blood, probably also may have the 
same effect. Blot specially mentions albuminuria as one of these, 
and Saboia states that in Brazil secondary hemorrhage is a common 
symptom of miasmatic poisoning, and can only be cured by change 
of air and the free use of quinine. 1 

Local Causes. — Local conditions seem, however, to be more fre- 
quent factors in the production of secondary hemorrhage. These 
may be generally classed under the following heads: — 

1. Irregular and inefficient contraction of the uterus. 

2. Clots in the uterine cavity. 

3. Portions of retained placenta or membranes. 

4. Retroflexion of the uterus. 

5. Laceration or inflammatory state of the cervix. 

6. Thrombosis or hematocele of the cervix or vulva. 

7. Inversion of the uterus. 

8. Fibroid tumors or polypus of the uterus. 

The first four of these need only now be considered, the others 
being described elsewhere. 

Relaxation of, and Clots in, the Uterus. — Relaxation of the uterus 
and distension of its cavity by coagula may give rise to hemorrhage, 
although not so readily as immediately after delivery, for coagula of 
considerable size are often retained in utero for many days after 
labor. The uterus will be found larger than it ought to be, and 
tender on pressure. Usually the coagula are expelled with severe 
after-pains; but this may not take place, and hemorrhage may ensue 
several days after delivery. Or there may be only a relaxed state 
of the uterus without retained coagula. Bassett relates 4 cases traced 
to these causes, and several illustrations will be found in McCIin- 
tock's paper. Portions of retained placenta or membranes are more 
frequent causes. The retention may be due to carelessness on the 
part of the practitioner, especially if he have removed the placenta 
by traction, and failed to satisfy himself of its integrity. It may, 
however, often be due to circumstances entirely beyond his control; 
such as adherent placenta, which it is impossible to remove without 

1 Saboia, Traits des Accouchements, p. 819. 



418 LABOR. 

leaving portions in utero, or more rarely placenta succenturia. In 
the latter case there is a small supplementary portion of placental 
tissue developed entirely separate from the general mass, and it may 
remain in utero without the practitioner having the least suspicion 
of its existence. Portions of the membranes are very apt to be left 
in utero. It is to prevent this that they should be twisted into a 
rope, and extracted very gently after expression of the placenta. 
Hemorrhage from these causes generally does not occur until at least 
a week after delivery, and it may not do so until a much longer time 
has elapsed. In 4 cases, recorded by Mr. Bassett, it commenced on 
the twelfth, tenth, fourteenth, and thirty-second day. It may come 
on suddenly and continue ; or it may stop, and recur frequently at 
short intervals. In my experience retention of portions of the pla- 
centa is very common after abortion, when adhesions are more gene- 
rally met with than at term. In addition to the hemorrhage there 
is often a fetid discharge, due to decomposition of the retained por- 
tion, and possibly more or less marked septicemic symptoms, which 
may aid in the diagnosis. The placenta or membranes may simply 
be lying loose as foreign bodies in the uterine cavity ; or they may 
be organically attached to the uterine walls, when their removal will 
not be so easily effected. 

Retroflexion. — Barnes has especially pointed out the influence of 
retroflexion of the uterus in producing secondary hemorrhage, 1 which 
seems to act by impeding the circulation at the point of flexion, and 
thus arresting the process of involution. 

In every case in which secondary hemorrhage occurs to any extent, 
careful investigation into the possible causes of the attack, and an 
accurate vaginal examination, are imperatively required. If it be 
due to general and constitutional causes only, we must insist on the 
most absolute rest on a hard bed in a cool room, and on the absence 
of all causes of excitement. The liquid extract of ergot will be very 
generally useful in 3j doses repeated every six hours. McClintock 
strongly recommends the tincture of Indian hemp, which may be ad- 
vantageously combined with the ergot, in doses of 10 or 15 minims, 
suspended in mucilage. Astringent vaginal pessaries of matico or 
perchloride of iron may be used. Special attention should be paid 
to the state of the bowels, and, if the rectum be loaded, it should be 
emptied by enemata. In more chronic cases a mixture of ergot, 
sulphate of iron, and small doses of sulphate of magnesia, will prove 
very serviceable. This is more likely to be effectual when the bleed- 
ing is of an atonic and passive character. McClintock speaks strongly 
in favor of the application of a blister over the sacrum. "When the 
hemorrhage is excessive, more effectual local treatmentVill be re- 
quired. Cazeaux advises plugging of the vagina. Although this 
cannot be considered so dangerous as immediately after delivery, 
inasmuch as the uterus is not so likely to dilate above the plug, 
still it is certainly not entirely without risk of favoring concealed 
internal hemorrhage. If it be used at all, a firm abdominal pad 

1 Obstetric Operations, p. 492. 



RUPTURE OF THE UTERUS. 419 

should be applied, so as to compress the uterus ; and the abdomen 
should be examined, from time to time, to insure against the possi- 
bility of uterine dilatation. With these precautions the plug may 
prove of real value. In any case of really alarming hemorrhage I 
should be disposed rather to trust to the application of styptics to 
the uterine cavity. The injection of fluid in bulk, as after delivery, 
could not be safely practised, on account of the closure of the os and 
the contraction of the uterus. But there can be no objection to 
swabbing out the uterine cavity with a small piece of sponge attached 
to a handle, and saturated in a solution of the perchloride of iron. 
There are few cases which will resist this treatment. 

If we have reason to suspect retained placenta or membranes, or 
if the hemorrhage continue or recur after treatment, a careful ex- 
ploration of the interior of the womb will be essential. On vaginal 
examination, we may possibly feel a portion of the placenta protrud- 
ing through the os, which can then be removed without difficulty. 
If the os be closed, it must be dilated with sponge or laminaria tents, 
or by a small -sized Barnes' bag, and the uterus can then be thoroughly 
explored. This ought to be done under chloroform, as it cannot be 
effectually accomplished without introducing the whole hand into 
the vagina, which necessarily causes much pain. If the placenta or 
membranes be loose in the uterine cavity, they may be removed at 
once ; or, if they be organically attached, they may be carefully 
picked off. The uterus should at the same time, and as long as the 
os remains patulous, be thoroughly washed out with Condy's fluid 
and water, to diminish the risk of septicaemia. 

Retroflexion can readily be detected by vaginal examination, and 
the treatment consists in careful reposition with the hand, and the 
application of a large-sized Hodges' pessary. 

[In managing the convalescence after excessive hemorrhage it is 
of great importance to replace the loss as rapidly as possible, in order 
to avoid serious diseases resulting from exhaustion. To accomplish 
this, we are usually in the habit of giving the essence of from three 
to seven pounds of beef per diem, for the first two weeks, and have 
given as high as eleven. It is remarkable how soon this restores the 
health and strength of the woman. — Ed.] 



CHAPTER XYI. 

RUPTURE OF THE UTERUS, ETC. 

Bupture of the uterus is one of the most dangerous accidents of 
labor, and until of late years it has been considered almost necessarily 
fatal, and beyond the reach of treatment. Fortunately it is not of 



420 LABOR. 

very frequent occurrence, although the published statistics vary so 
much that it is by no means easy to arrive at any conclusion on this 
point. The explanation is, no doubt, that many of the tables con- 
found partial and comparatively unimportant lacerations of the cer- 
vix and vagina, with rupture of the body and fundus. It is only in 
large lying-in institutions, where the results of cases are accurately 
recorded, that anything like reliable statistics can be gathered, for 
in private practice the occurrence of so lamentable an accident is 
likely to remain unpublished. . To show the difference between the 
figures given by authorities, it may be stated that, while Burns cal- 
culates the proportion to be 1 in 940 labors, Ingleby fixes it as 1 in 
1300 or 1400, Churchill as 1 in 1331, and Lehmann as 1 in 2433. 
Dr. Jolly, of Paris, has published an excellent thesis containing much 
valuable informatioii. 1 He finds that out of 782,741 labors, 230 rup- 
tures, excluding those of the vagina or cervix, occurred, that is 1 in 
3403. 

Seat of Rupture. — Lacerations may occur in any part of the 
uterus — the fundus, the body, or the cervix. Those of the cervix 
are comparatively of small consequence, and occur, to a slight ex- 
tent, in almost all first labors. Only those which involve the supra- 
vaginal portion are of realiy serious import. Euptures of the upper 
part of the uterus are much less frequent than of the portion near 
the cervix ; partly, no doubt, because the fundus is beyond the reach 
of the mechanical causes to which the accident can, not unfrequently, 
be traced, and partly because the lower third of the organ is apt to 
be compressed between the presenting part and the bony pelvis. The 
site of placental insertion is said by Madame La Chapelle to be rarely 
involved in the rupture, but it does not always escape, as numerous 
recorded cases prove. The most frequent seat of rupture is near the 
junction of the body and neck, either anteriorly or posteriorly, op- 
posite the sacrum, or behind the symphysis pubis, but it may occur 
at the sides of the lower segment of the uterus. In some cases 
the entire cervix has been torn away, and separated in the form of 
a ring. 

Rupture may be Partial or Complete. — The laceration may be 
partial or complete ; the latter being the more common. The mus- 
cular tissue alone may be torn, the peritoneal coat remaining intact; 
or the converse majr occur, and then the peritoneum is often fissured 
in various directions, the muscular coat being unimplicated. The 
extent of the injury is very variable ; in some cases being only a 
slight tear, in others forming a large aperture, sufficiently extensive 
to allow the foetus to pass into the abdominal cavity. The direction 
of the laceration is as variable as the size, but it is more frequently 
vertical than transverse or oblique. The edges of the tear are irregu- 
lar and jagged ; probably on account of the contraction of the mus- 
cular fibres, which are frequently softened, infiltrated with blood, 
and even gangrenous. Large quantities of extravasated blood will 

1 Rupture uterine pendant le Travail, Paris, 1873. 



RUPTURE OF THE UTERUS. 421 

be found in the peritoneal cavity ; such hemorrhage, indeed, being 
one of the most important sources of danger. 

Causes are either Predisposing or Exciting. — The causes are divided 
into predisposing and exciting / and the progress of modern research 
tends more and more to the conclusion that the cause which leads to 
the laceration could only have operated because the tissue of the 
uterus was in a state predisposed to rupture, and that it would have 
had no such effect on a perfectly healthy organ. What these pre- 
disposing changes are, and how they operate, is yet far from being 
known, and the subject offers a fruitful field for pathological investi- 
gation. 

Said to be more Common in Multiparse. — It is generally believed 
that lacerations are more common in multipara than in primiparse. 
Tyler Smith contended that ruptures are relatively as common in 
first as in subsequent labors. Statistics are not sufficiently accurate 
or extensive to justify a positive conclusion, but it is reasonable to 
suppose that the pathological changes, presently to be mentioned as 
predisposing to laceration, are more likely to be met with in women 
whose uteri have frequently undergone the alteration attendant on 
repeated pregnancies. Age seems to have considerable influence, as 
a large proportion of cases have occurred in women between thirty 
and forty years of age. 

Alterations in the tissues of the uterus are probably of very great 
importance in predisposing to the accident, although our information 
on this point is far from accurate. Among these are morbid states 
of the muscular fibres, the result of blows or contusions during preg- 
nancy; premature fatty degeneration of the muscular tissues, an 
anticipation, as it were, of the normal involution after delivery ; 
fibroid tumors, or malignant infiltration of the uterine walls, which 
either produce a morbid state of the tissues, or act as an impediment 
to the expulsion of the foetus. The importance of such changes has 
been specially dwelt on by Murphy in this country, and by Lehmann 
in Germany, and it is impossible not to concede their probable influ- 
ence in favoring laceration. However, as yet these views are founded 
more on reasonable hypothesis than on accurately observed patho- 
logical facts. 

Another and very important class of predisposing causes are those 
which lead to a want of proper proportion between the pelvis and 
the foetus. 

Deformity in Pelvis is a Frequent Cause. — Deformity of the pelvis 
has been very frequently met with in cases in which the uterus has 
ruptured. Thus out of 19 cases, carefully recorded by Eadford, 1 the 
pelvis was contracted in 11, or more than one-half. Eadford makes 
the curious observation that ruptures seem more likely to occur 
when the deformity is only slight ; and he explains this by supposing 
that in slight deformities the lower segment of the uterus engages 
in the brim, and is, therefore, much subjected to compression, while 
in extreme deformity the os and cervix uteri remain above the brim, 

1 Obst. Trans., vol. viii. 



422 LABOR. 

the body and fundus of the uterus hanging down between the thighs 
of the mother. This explanation is reasonable ; but the rarity with 
which ruptured uterus is associated with extreme pelvic deformity 
may rather depend on the infrequency of advanced degrees of con- 
traction. 

Malpresentation. — Amongst causes of disproportion depending on 
the foetus are either malpresentation, in which the pains cannot effect 
expulsion, or undue size of the presenting part. In the latter way 
may be explained the observation that rupture is much more fre- 
quently met with male than with female children, on account, no 
doubt, of the larger size of the head in the former. The influence 
of intra-uterine hydrocephalus was first prominently pointed out by 
Sir James Simpson, 1 who states that out of 7-i cases of intra-uterine 
hydrocephalus the uterus ruptured in 16. In all such cases of dis- 
proportion, whether referable to the pelvis or foetus, rupture is pro- 
duced in a twofold manner, either by the excessive and fruitless 
uterine contractions, which are induced by the efforts of the organ 
to overcome the obstacle ; or by the compression of the uterine tissue 
between the presenting part and the bony pelvis, leading to inflam- 
mation, softening, and even gangrene. 

Mechanical Injury of JRupture. — The proximate cause of rupture 
may be classed under two heads — mechanical injury, and excessive 
uterine contraction. Under the former are placed those uncommon 
cases in which the uterus lacerates as the result of some injury in 
the latter months of pregnancy, such as blows, falls, and the like. 
Not so rare, unfortunately, are lacerations produced by unskilled 
attempts at delivery on the part of the medical attendant, such as 
by the hand during turning, or by the blades of the forceps. Many 
such cases are on record, in which the accoucheur has used force and 
violence, rather than skill, in his attempts to overcome an obstacle. 
That such unhappy results of ignorance are not so uncommon as they 
ought to be is proved by the figures of Jolly, who has collected 71 
cases of rupture during podalic version, 37 caused by the forceps, 10 
by the cephalotribe, and 30 during other operations, the precise nature 
of which is not stated. 2 The modus operandi of protracted and in- 
effectual uterine contractions, as a proximate cause of rupture, is 
sufficiently evident, and need not be dwelt on. It is necessary to 
allude, however to the effect of ergot, incautiously administered, as 
a producing cause. There is abundant evidence that the injudicious 
exhibition of this drug has often been followed by laceration of the 
unduly stimulated uterine fibres. Thus Trask, talking of the sub- 
ject, says that Meigs had seen three cases, and Bedford four, distinctly 
traceable to this cause. Jolly found that ergot had been administered 
largely in 33 cases in which rupture occurred. 

Premonitory Symptoms. — Some have believed that the impending 
occurrence of rupture could frequently be ascertained by peculiar 
premonitory symptoms, such as excessive and acute crampy pains 
about the lower part of the abdomen, due to the compression of part 

1 Selected Obst. Works, p. 385. 2 Op. cit., p. 38. 



RUPTURE OF THE UTERUS. 423 

of the uterine walls. These are far too indefinite to be relied on, 
and it is certain that the rupture generally takes place without any 
symptoms that would have afforded reasonable grounds for suspicion. 

General Symptoms. — The symptoms are often so distinct and alarm- 
ing as to leave no doubt as to the nature of the case ; not unfrequently, 
however, especially if the laceration be partial, they are by no means 
so well marked, and the practitioner may be uncertain as to what has 
taken place. In the former class of cases a sudden excruciating pain 
is experienced in the abdomen, generally during the uterine contrac- 
tions, accompanied by a feeling, on the part of the patient, of some- 
thing having given way. In some cases this has been accompanied 
by an audible sound, which has been noticed by the bystanders. At 
the same time there is generally a considerable escape of blood from 
the vagina, and a prominent symptom is the sudden cessation of the 
previously strong pains. Alarming general symptoms soon develop, 
partly due to shock, partly to loss of blood, both external and internal. 
The face exhibits the greatest suffering, the skin becomes deadly cold 
and covered with a clammy sweat, and fainting, collapse, rapid feeble 
pulse, hurried breathing, vomiting, and all the usual signs of extreme 
exhaustion quickly follow. 

Results of Abdom ina I a nd Vaginal Exa m in ations. — Abdominal pal- 
pation and vaginal examination both afford characteristic indications 
in well-marked cases. If the child, as often happens, have escaped 
entirely, or in great part, into the abdominal cavity, it may be readily 
felt through the abdominal walls; while, in the former case, the par- 
tially contracted uterus may be found separate from it in the form 
of a globular tumor, resembling the uterus after delivery. Per 
vaginam it may generally be ascertained that the presenting part has 
suddenly receded, and can no longer be made out: or some other 
part of the foetus may be found in its place. If the rupture be ex- 
tensive, it may be appreciable on vaginal examination, and, some- 
times, a loop of intestine may be found protruding through the tear. 
Other occasional signs have been recorded, such as an emphysema- 
tous state of the lower part of the abdomen, resulting from the 
entrance of air into the cellular tissue ; or the formation of a san- 
guineous tumor in the hypogastrium, or vagina. These are too 
uncommon, and too vague, to be of much diagnostic value. 

Symptoms are sometimes Obscure. — Unfortunately the symptoms 
are by no means always so distinct, and cases occur in which most 
of the reliable indications, such as the sudden cessation of the pains, 
the external hemorrhage, and the retrocession of the presenting part. 
may be absent. In some cases, indeed, the symptoms have been so 
obscure that the real nature of the case has only been detected after 
death. It is rarely, however, that the occurrence of shock and pros- 
tration is not sufficiently distinct to arouse suspicion, even in the 
absence of the usual marked signs. In not a few cases distinct and 
regular contractions have gone on after laceration, and the child has 
even been born in the usual way. Of course, in such a case, mistake 
is very possible. So curious a circumstance is difficult of explana- 
tion. The most probable way of accounting for it is, that the lacera- 



424 LABOR. 

tion has not implicated the fundus of the uterus, which contracted 
sufficiently energetically to expel the foetus. Hence it will be seen 
that the symptoms are occasionally obscure, and the practitioner 
must be careful not to overlook the occurrence of so serious an 
accident, because of the absence of the usual and characteristic 
symptoms. 

Prognosis. — The prognosis is necessarily of the gravest possible 
character, but modern views as to treatment perhaps justify us in 
saying that it is not so absolutely hopeless as has been generally 
taught in our obstetric works. When we reflect on what has oc- 
curred — the profound nervous shock ; the profuse hemorrhage, both 
external, and especially into the peritoneal cavity, where the blood 
coagulates and forms a foreign body ; the passage of the uterine 
contents into the abdomen, with the inevitable result of inflamma- 
tion and its consequences, if the patient survive the primary shock ; 
— the enormous fatality need cause no surprise. Jolly has found that 
out of 580 cases 100 recovered, that is in the proportion of 1 out of 
6. This is a far more favorable result than we are generally led to 
anticipate ; and as many of the recoveries happened in apparently 
the most desperate and unfavorable cases, we should learn the 
lesson that we need not abandon all hope, and should at least en- 
deavor to rescue the patient from the terrible dangers to which she 
is exposed. 

As regards the child the prognosis is almost necessarily fatal ; and 
indeed, the cessation of the foetal heart- sounds has been pointed out 
by McClintock as a sign of rupture in doubtful cases. The shock, 
the profuse hemorrhage, and the time that must necessarily elapse 
before the delivery of the child, are of themselves quite sufficient to 
explain the fact that the foetus is almost always dead. 

Treatment. — From what has been said of the impossibility of fore- 
telling the occurrence of rupture, it must follow that no reliable pro- 
phylactic treatment can be adopted, beyond that which is a matter 
of general obstetric principle, viz., timely interference when the 
uterine contractions seem incapable of overcoming an obstacle to de- 
livery, either on the part of the pelvis or foetus. 

Indications after Rupture has taken place. — After rupture the main 
indications are to effect the removal of the child and the placenta, 
to rally the patient from the effects of the shock, and, if she survives 
so long, to combat the subsequent inflammation and its consequences. 
By far the most important point to decide is the best means to be 
adopted for the removal of the child ; for it is admitted by all that 
the hopeless expectancy that was recommended by the older accou- 
cheurs, or, in other words, allowing the patient to die without making 
any effort to save her, is quite inadmissible. If the foetus be entirely 
within the uterine cavity, no doubt the proper course to pursue is to 
deliver at once per vias naturales 1 either by turning, by forceps, or 
by cephalotripsy. If any part other than the head present, turning 
will be best, great care being taken to avoid further increase of the 
laceration. If the head be in the cavity or at the brim of the pelvis, 
and within easy reach of the forceps, it may be cautiously applied, 



RUPTURE OF THE UTERUS. 425 

the child being steadied by abdominal pressure, so as to facilitate its 
application. If there be, as is so often the case, some slight amount 
of pelvic contraction, it may be preferable to perforate and apply the 
cephalotribe, so as to avoid any forcible attempts at extraction, which 
might unduly exhaust the already prostrate patient, and turn the 
scale against her. This will be the more allowable since the child 
is, as we have seen, almost always dead, and we might readily ascer- 
tain if it be so by auscultation. 

Removal of the Placenta. — After delivery extreme care must be 
taken in removing the placenta, and for this it will be necessary to 
introduce the hand. The placenta will generally be in the uterus, 
for if the rent be not large enough for the child to pass through, it 
may be inferred that the placenta will not have clone so either. If 
it has escaped from the uterus, very gentle traction on the cord may 
bring it within reach of the hand, and so the passage of the hand 
through the tear to search for it will be avoided. 

Treatment when the Foetus has Escaped out of the Uterus. — There 
can be but little doubt that, in the cases indicated, such is the proper 
treatment, and that which affords the mother the best chance. Un- 
fortunately, the cases in which the child remains entirely in utero 
are comparatively uncommon, and generally it will have escaped 
into the abdomen, along with much extravasated blood. The usual 
plan of treatment recommended, under such circumstances, is to pass 
the hand through the fissure (some have even recommended that it 
should be enlarged by incision if necessary), to seize the feet of the 
foetus, to drag it back through the torn uterus, and then to reintro- 
duce the hand to search for and remove the placenta. Imagine what 
occurs during the process. The hand gropes blindly among the ab- 
dominal viscera, the forcible dragging back of the foetus necessarily 
tears the uterus more and more, and, above all, the extravasated 
blood remains as a foreign body in the peritoneal cavity, and neces- 
sarily gives rise to the most serious consequences. It is surely hardly 
a matter of surprise that there is scarcely a single case on record of 
recovery after this procedure. 

Reasons favoring Gastrotomy. — Of late years a strong feeling has 
existed that, whenever the child has entirely, or in great part, escaped 
into the abdominal cavity, the operation of gastrotomy affords the 
mother a far better chance of recovery ; and it has now been per- 
formed in many cases with the most encouraging results. It is easy 
to see why the prospects of success are greater. The uterus being 
already torn, and the peritoneum opened, the only additional danger 
is the incision of the abdominal parietes, which gives us the oppor- 
tunity of sponging out the peritoneal cavity, as in ovariotomy, and 
of removing all the extravasated blood, the retention of which so 
seriously adds to the dangers of the case. Another advantage is 
that, if the patient be excessively prostrate, the operation may be 
delayed until she has somewhat rallied from the effects of the shock, 
whereas delivery by the feet is generally resorted to as soon as the 
rupture is recognized, and when the patient is in the worst possible 
condition for interference of any kind. 
28 



426 



LABOR. 



Comparative Results of Various Methods of Treatment. — Jolly has 
carefully tabulated the results of the various methods of treatment, 
and, making every allowance for the unavoidable errors of statistics, 
it seems beyond all question that the results of gastrotomy are so 
greatly superior to those of other plans, that I think its adoption 
may fairly be laid down as a rule whenever the foetus is no longer 
within the uterine cavity. 

Comparative Eesults of Various Methods of Treatment after 
Rupture of Uterus. 



Treatment. 


No. of cases. 


Deaths. 


Recoveries. 


Per cent, of 
recoveries. 


Expectation .... 
Extraction per vias naturales 
Gastrotomy 


144 

382 

38 


142 

310 

12 


2 
72 
26 


1.45 
19 
68.4 



Of course this table will not justify the conclusion that 68 per 
cent, of the cases of ruptured uterus in which gastrotomy is per- 
formed will recover ; but it may fairly be taken as proving that the 
chances of recovery are at least three or four times as great as when 
the more usual practice is adopted. 

[According to Dr. Trask's reports, 1 27 recovered, out of 115 that 
were undelivered, and 77 out of 207, delivered : 29 operations by 
laparotomy saved 22 women. "We have been at considerable pains 
to find out what has been the result of this operation in the United 
States, and thus far have collected 30 cases, with a saving of 21 
women and 1 child. The child saved resulted from an immediate 
operation with a pocket-knife, performed by Dr. Tupper, of Bay 
City, Michigan, in 1869 : the woman recovered. We are disposed 
to believe that a general record of cases, published and unpublished, 
would show a saving of from 60 to 65 per cent, of the women, which 
is lower than that claimed by Trask and Jolly, collected from pub- 
lished reports. We, however, believe that care and promptness ought 
to save 75 per cent, of the women, and more than the percentage of 
children on record. — Ed.] 

Necessity of Care in Performing the Operation. — It is perhaps need- 
less to say that the operation must be performed with the same 
minute care that has raised ovariotomy to its present pitch of per- 
fection, and that especial attention should be paid to the sponging 
out of the peritoneum, and the removal of foreign matters. 

Recapitulation. — To recapitulate, I think what has been said jus- 
tifies the following rules of treatment after rupture: — 

1. If the head or presenting part be above the brim, and the foetus 
still in utero — forceps, turning, or omphalotripsy, according to circum- 
stances. 

2. If the head be in the pelvic cavity — forceps or cephalotripsy. 

[' Am. Journ. Med. Sci., vol. xv. N. S. 1848, pp. 104, 383 ; vol. xxxii. p. 81.] 



RUPTURE OF THE UTERUS. 427 

3. If the foetus have wholly, or in great part, escaped into the 
abdominal cavity — gastrotomy. 

Subsequent Treatment. — As to the subsequent treatment little need 
be said, since in this we must be guided by general principles. The 
chief indication will be to remove shock and rally the patient by 
stimulants, etc., and to combat secondary results by opiates and other 
appropriate remedies. 

Lacerations of the vagina occasionally take place, and in the great 
majority of cases, they are produced by instruments, either from a 
want of care in their introduction, or from nndue stretching of the 
vaginal walls during extraction with the forceps. Slight vaginal 
lacerations are probably much more common after forceps delivery 
than is generally believed to be the case. As a rule they are pro- 
ductive of no permanent injury, although it must not be forgotten 
that every breach of continuity increases the risk of subsequent 
septic absorption. When the laceration is sufficiently deep to tear 
through the recto- vaginal septum, or the anterior vaginal wall, the 
passage of the urine or feces is apt to prevent its edges uniting; then 
that most distressing condition, recto- vaginal, or vesico- vaginal fistula 
is established. 

It must not be supposed that fistulas are often the result of injury 
during operative interference. That is a common but very erroneous 
opinion both among the profession and the public. In the vast 
majority of cases the fistulous opening is the consequence of a slough 
resulting from inflammation, produced by long-continued pressure of 
the vaginal walls between the child's head and the bony pelvis, in 
cases in which the second stage has been allowed to go on too long. 
In most of these cases instruments were doubtless eventually used, 
and they get the blame of the accident; whereas the fault lay, not 
in their being employed, but rather in their not having been used 
soon enough to prevent the contusion and inflammation which ended 
in sloughing. 

When vesico-vaginal fistulae are the result of lacerations during 
labor, the urine must escape at once, but this is rarely the case. In 
the large majority of cases the urine does not pass per vaginam until 
more than a week after delivery, showing that a lapse of time is 
necessary for inflammatory action to lead to sloughing. In order to 
throw some light on these points, on which very erroneous views 
have been held, I have carefully examined the histories, from various 
sources, of 63 cases of vesico-vaginal fistula. 

1st. In 20 no instruments were employed. Of these, there were 



in labor under 24 hours 

from 24 to 48 hours 

" 48 to 70 " 



70 to 80 " 

80 hours and upwards 



2 

8 1 
2 
7 
1 

20 



1 But of these in 7 no precise time is stated. 6 of them are marked very tedious* 
therefore they probably exceeded the limit. 



428 LABOR. 

Therefore out of these 20 cases one-half were certainly more than 
48 hours in labor, and 6 of the remaining 10 were probably so also. 
In only 1 of them is the urine stated to have escaped per vaginam 
immediately after delivery. In 7 it is said to have done so within 
a week, and in the remainder after the seventh day. 

2d. In 34 cases instruments were used, but there is no evidence of 
their having produced the accident. Of these, there were in labor 
under 24 hours ...... 2 

from 24 to 48 hours ... 8 

" 48 to 72 " . . . 10 
" 72 hours and upwards . 14 

34 

The urine escaped within 24 hours in 2 cases only, within a week in 
16, and after the seventh day in 15. 

So that here again we have the history of unduly protracted 
delivery, 24 out of the 34 having been certainly more than 48 hours 
in labor.. 

3d. In 9 cases the histories show that the production of the fistula 
may fairly be ascribed to the unskilled use of instruments. Of these, 
there were in labor under 24 hours ... 7 
from 24 to 48 hours ... 1 
" 48 to 72 " . . . 1 



The urine escaped at once in 7 cases, and in the remaining 2 after 
the seventh day. 

These statistics seem to me to prove, in the clearest manner, that, 
in the large majority of cases, this unhappy accident may be directly 
traced to the bad practice of allowing labor to drag on many hours 
in the second stage without assistance, and not to premature instru- 
mental interference. 

Treatment. — As to the treatment of vaginal laceration little can 
be said. In the slighter cases vaginal injections of diluted Condy's 
fluid will be useful to lessen the risk of septic absorption ; and the 
graver, when vesico-vaginal or recto- vaginal fistulas have actually 
formed, are not within the domain of the obstetrician, but must be 
treated surgically at some future date. 



INVERSION OF THE UTERUS. 429 



CHAPTEE XVII. 

INVERSION" OF THE UTERUS. 

Inversion of the uterus shortly after the birth of the child is one 
of the most formidable accidents of parturition, leading to symptoms 
of the greatest urgency, not rarely proving fatal, and requiring prompt 
and skilful treatment. Hence it has obtained an unusual amount of 
attention, and there are few obstetric subjects which have been more 
carefully studied. 

An Accident of Great Rarity. — Fortunately, the accident is of great 
rarity. It was only observed once in upwards of 190,800 deliveries 
at the Eotunda Hospital since its foundation in 1745 ; and many 
practitioners have conducted large midwifery practices for a lifetime 
without ever having witnessed a case. It is none the less needful, 
however, that we should be thoroughly acquainted with its natural 
history, and with the best means of dealing with the emergency when 
it arises. 

Division into Acute and Chronic Forms. — Inversion of the uterus 
may be met with in the acute or chronic form; that is to say, it may 
come under observation either immediately or shortly after its occur- 
rence, or not until after a considerable lapse of time, when the invo- 
lution following pregnancy has been completed. The latter falls 
more properly under the province of the gynaecologist, and involves 
the consideration of many points that would be out of place in a 
work on obstetrics. Here, therefore, the acute form alone is con- 
sidered. 

Description of Inversion. — Inversion consists essentially in the en- 
larged and empty uterus being turned inside out, either partially or 
entirely ; and this may occur in various degrees, three of which are 
1 usually described, and are practically useful to bear in mind. In 
the first and slightest degree there is merely a cup-shaped depression 
of the fundus (Fig. 139); in the second the depression is greater, so 
that the inverted portion forms an introsusception, as it were, and 
projects downwards through the os in the form of a round ball, not 
unlike the body of a polypus, for which, indeed, a careless observer 
might mistake it; and, thirdly, there is the complete variety, in 
which the whole organ is turned inside out and maj even project 
beyond the vulva. 

Its Symptoms. — The sj^mptoms are generally very characteristic, 
although, when the amount of inversion is small, they may entirely 
escape observation. They are chiefly those of profound nervous 
shock, viz., fainting, small, rapid, and feeble pulse, possibly convul- 
sions and vomiting, and a cold, clammy skin. Occasionally severe 
abdominal pain, and cramp and bearing down are felt. Hemorrhage 



430 



LABOR. 




Partial Inversion of the Fundus. 
(From a preparation in the museum of 
Guy's Hospital.) 



and tender swelling, 



Fig. 139. is a frequent accompaniment, some- 

times to a very alarming extent, espe- 
cially if the placenta be partially or 
entirely detached. The loss of blood 
depends to a great extent on the con- 
dition of the uterine parietes. If there 
be much contraction of the part that is 
not inverted, the introsuscepted part 
may be sufficiently compressed to pre- 
vent any great loss. If the entire organ 
be in a state of relaxation, the loss may 
be excessive. 

Results of Physical Examination. — 
The occurrence of such symptoms 
shortly after delivery would of neces- 
sity lead to an accurate examination, 
when the nature of the case may be at 
once ascertained. On passing the finger 
into the vagina, we either find the entire 
uterus forming a globular mass, to 
which the placenta is often attached ; 
or, if the inversion be incomplete, the 
vagina is occupied by a firm, round, 
which can be traced upwards through the 
os uteri. The hand placed on the abdomen will detect the absence 
of the round ball of the contracted uterus, and bi-manual examina- 
tion may even enable us to feel the cup-shaped depression at the 
site of inversion. 

Differential Diagnosis. — -When such signs are observed immedi- 
ately after delivery, mistake is hardly possible. Numerous instances, 
however, are recorded in which the existence of inversion was not 
immediately detected, and the tumor formed by it only observed 
after the lapse of several days, or even longer, when the general 
symptoms led to vaginal examination. It is probable that, in such 
cases, a partial inversion had taken place shortly after delivery, 
which, as time elapsed, became gradually converted into the more 
complete variety. In a case of this kind, as in a chronic inversion, 
some care is necessary to distinguish the inversion from a uterine 
polypus, which it closely resembles. The cautious insertion of the 
sound will render the diagnosis certain, since its passage is soon ar- 
rested in inversion, while, if the tumor be polypoid, it readily passes 
in as far as the fundus. 

Manner in which Inversion is Produced. — The mechanism by which 
inversion is produced is well worthy of study, and has given rise to 
much difference of opinion. 

Occasionally produced by Accidental Mechanical Causes. — A very 
general theory is, that it is caused, in many cases, by mismanage- 
ment of the third stage of labor, either by traction on the cord, the 
placenta being still adherent, or by improperly applied pressure on 
the fundus ; the result of both these errors being a cup-shaped cle- 



INVERSION OF THE UTERUS. 431 

pression of the fundus, which is subsequently converted into a more 
complete variety of inversion. That such causes may suffice to start 
the inversion cannot be doubted, but it is probable that their fre- 
quency has been much exaggerated. Still there are numerous re- 
corded cases in which the commencement of the inversion can be 
traced to them. Improperly applied pressure (as when the whole 
body of the uterus is not grasped in the hollow of the hand, but 
when a monthly nurse, or other un instructed person, presses on the 
lower part of the abdomen, so as simply to push down the uterus en 
masse) is often mentioned in histories of the accident. Thus in the 
''Edinburgh Medical Journal 1 ' for June, 1848, a case is related in 
which the patient would not have a medical man, but was attended 
by a midwife, who, after the birth of the child, pulled on the cord, 
while the patient herself clasped her hands and pushed down her 
abdomen, at the same time straining forcibly, when the uterus be- 
came inverted, and the patient died of hemorrhage before assistance 
could be procured. Here both the mechanical causes mentioned 
were in operation. In several cases it is mentioned that the accident 
occurred while the nurse was compressing the abdomen. That the 
accident is practically impossible when firm and equable contraction 
has taken place, cannot be questioned. Hence ib is of paramount 
importance that the practitioner should himself carefully attend to 
the conduct of the third stage of labor. 

Often Occurs Spontaneously. — In a large proportion of cases no 
mechanical causes can be traced, and the occurrence of spontaneous 
inversion must be admitted. There are various theories held as to 
how this occurs. Partial and irregular contraction of the uterus is 
generally admitted to be an important factor in its production: but 
it is still a matter of dispute whether the inversion is produced mainly 
by an active contraction of the fundus and body of the uterus, the 
lower portion and cervix being in a state of relaxation ; or whether 
the precise reverse of this exists, the fundus being relaxed and in a 
state of quasi-paralysis, while the cervix and lower portion of the 
uterus are irregularly contracted. The former is the view main- 
tained by Eadford and Tyler Smith, while the latter is upheld by 
Matthews Duncan. 

Evidence in Favor of Duncan's Theory. — There are good clinical 
reasons for believing that Duncan's view more nearly corresponds 
with the true facts of the case ; for, if the fundus and body of the 
uterus be really in a state of active contraction, while the cervix is 
relaxed, we have, as Duncan points out, the very condition which is 
normal and desirable after delivery, and that which we do our best 
to produce. If, however, the opposite condition exist, and the fundus 
be relaxed, while the lower portion is spasmodically contracted, a 
state exists closely allied to the so-called hour-glass contraction. 
Supposing now any cause produces a partial depression of the fundus, 
it is easy to understand how it may be grasped by the contracted 
portion, and carried more and more down, in the manner of an intro- 
susception, until complete inversion results. That such partial paraly- 
sis of the uterine walls often exists, especially about the placental 



432 



LABOR. 



Fig. 140. 



site, was long ago pointed out by Kokitansky, and other pathologists. 
This theory supposes the original partial depression and relaxation 
of the fundus. How this is often produced by mismanagement of 
the third stage has already been pointed out ; but, even in the absence 
of such causes, it may result from strong bearing-down efforts on the 
part of the patient, or, as Duncan holds, from the absence of the 
retentive power of the abdomen. Indeed the incompatibility of an 
actively contracted state of the fundus with the partial depression 
which is essential, according to both views, for the production of 
inversion, is the strongest argument in favor of Duncan's theory. 

Taylor's Theory. — A totally different view has more recently been 
sustained by Dr. Taylor, of New York, who maintains that "spon- 
taneous active inversion of the uterus rests 
upon prolonged natural and energetic ac- 
tion of the body and fundus; the cervix, 
the lower part, yielding first, is thus rolled 
out, or everted, or doubled up, as there is 
no obstruction from the contractility of the 
cervix, which is at rest or functionally 
paralyzed ; the body is gradually, some- 
times instantaneously, forced lower and 
lower, or inverted." 1 That partial inver- 
sion may commence at the cervix was 
pointed out by Duncan in his paper, who 
depicts it in the accompanying diagram 
(Fig. 140), and states it to be of not unfre- 
quent occurrence. It is not impossible that 
occasionally such a state of things should 
be carried on to complete inversion. But 
there are serious objections to the accep- 
tance of Dr. Taylor's view that such is the 
principal cause of inversion, since the pro- 
cess above described would be of necessity 
a slow and long-continued one, whereas nothing is more certain than 
that inversion is generally sudden and accompanied by acute symp- 
toms of shock, and is often attended by severe hemorrhage, which 
could not occur when such excessive contraction was taking place. 

Treatment. — The treatment of inversion consists in restoring the 
organ to its natural condition as soon as possible. Every moment's 
delay only serves to render restoration more difficult, as the inverted 
portion becomes swollen and strangulated ; Avhereas if the attempt 
at reposition be made immediately, there is generally comparatively 
little difficulty in effecting it. Therefore it is of the utmost import- 
ance that no time should be lost, and that we should not overlook a 
partial or incomplete inversion. Hence the occurrence of any unu : 
sual shock, pain, or hemorrhage after delivery, without an}^ readily 
ascertained cause, should always lead to a careful vaginal examina- 
tion. A want of attention to this rule has too often resulted in the 




Illustrating the Commencement 
of Inversion at the Cervix. (After 
Duncan). 



New York Med. Journ., 1872. 



INVERSION OF THE UTERUS. 483 

existence of partial inversion being overlooked, until its reduction 
was found to be difficult or impossible. 

Mode of Attempting Reduction. — In attempting to reduce a recent 
inversion, the inverted portion of the uterus should be grasped in 
the hollow of the hand and pushed gently and firmly upwards into 
its natural position, great care being taken to apply the pressure in 
the proper axis of the pelvis, and to use counter-pressure, by the 
left hand, on the abdominal walls. Barnes lays stress on the import- 
ance of directing the pressure towards one side, so as to avoid the 
promontory of the sacrum. The common plan of endeavoring to 
push back the fundus first has been well shown by McClintock 1 to 
have the disadvantage of increasing the bulk of the mass that has 
to be reduced, and he advises that, while the fundus is lessened in 
size by compression, we should, at the same time, endeavor to push 
up first the part that was less inverted, that is to say, the portion 
nearest the os uteri. Should this be found impossible, some assist- 
ance may be derived from the manoeuvre, recommended by Merriman 
and others, of first endeavoring to push up one side or wall of the 
uterus, and then the other, alternating the upward pressure from one 
side to the other as we advance. It often happens as the hand is 
thus applied, that the uterus somewhat suddenly rein verts itself, 
sometimes with an audible noise, much as an India-rubber bottle 
would do under similar circumstances. When reposition has taken 
place the hand should be kept for some time in the uterine cavit}^ to 
excite tonic contraction; or Barnes's suggestion of injecting a weak 
solution of perchloride of iron may be adopted, so as to constrict the 
uterine walls, and prevent a recurrence of the accident. 

It is hardly necessary to point out how much these manoeuvres 
will be facilitated by placing the patient fully under the influence of 
an anaesthetic. 

Management of the Placenta. — There has been much difference of 
opinion as to the management of the placenta in cases in which it is 
still attached when inversion occurs. Should we remove it before 
attempting reposition, or should we first endeavor to rein vert the 
organ, and subsequently remove the placenta? The removal of the 
placenta certainly much diminishes the bulk of the inverted portion, 
and, therefore, renders reposition easier. On the other hand, if there 
be much hemorrhage, as is so frequently the case, the removal of the 
placenta may materially increase the loss of blood. For this reason, 
most authorities recommend that an endeavor should be made at 
reduction before peeling off the after birth. But if any delay or 
difficulty be experienced from the increased bulk, no time should be 
lost, and it is in every way better to remove the placenta and en- 
deavor to reinvert the organ as soon as possible. 

Management of Cases detected some time after Delivery. — Supposing 
we meet with a case in which the existence of inversion has been 
overlooked for daj^s, or even for a week or two, the same procedure 
must be adopted ; but the difficulties are much greater, and the 

1 Diseases of W omen, p. 79. 



434 LABOR. 

longer the delay, the greater they are likely to be. Even now, 
however, a well-conducted attempt at taxis is likely to succeed. 
Should it fail, we must endeavor to overcome the difficulty by con- 
tinuous pressure applied by means of caoutchouc bags, distended 
with water, and left in the vagina. It is rarely that this will fail in 
a comparatively recent case, and such only are now under considera- 
tion. It is likely that by pressure, applied in this way for twenty- 
four or forty-eight hours, and then followed by taxis, any case 
detected before the involution of the uterus is completed may be 
successfully treated. 



PART IV. 

OBSTETRIC OPERATIONS. 



CHAPTEE I. 

INDUCTION OF PEEMATUEE LABOE. 

The first of the obstetric operations we have to consider is the 
induction of premature labor, an operation which, like the use of for- 
ceps, was first suggested and practised in this country, and the recog- 
nition of which, as a legitimate procedure, we also chiefly owe to the 
labor of our fellow-countrymen, in spite of much opposition both at 
home and abroad. It is not known with certainty to whom we owe 
the original suggestion; but we are told by Denman that in the year 
1756 there was a consultation of the most eminent physicians at that 
time in London, to consider the advantages which might be expected 
from the operation. The proposal met with formal approval, and 
was shortly after carried into practice by Dr. Macaulay, the patient 
being the wife of a linendraper in the Strand. From that time it 
has flourished in Great Britain, the sphere of its application has been 
largely increased, and it has been the means of saving many mothers 
and children, who would otherwise, in all probability, have perished. 
On the Continent, it w r as long before the operation was sanctioned or 
practised. Although recommended by some of the most eminent 
German practitioners, it was not actually performed until the year 
1804. In France the opposition was long-continued and bitter. 
Many of the leading teachers strongly denounced it, and the Academy 
of Medicine formally discountenanced it so late as the year 1827. 
The objections were chiefly based on religious grounds, but partly, 
no doubt, on mistaken notions as to the object proposed to be gained. 
Although frequently discussed, the operation was never actually car- 
ried into practice until the year 1831, when Stoltz performed it with 
success. Since that time opposition has greatly ceased, and it is now 
employed and highly recommended by the most distinguished ob- 
stetricians of the French schools. 

Objects of the Operation. — In inducing premature labor, we propose 
to avoid or lessen the risk to which, in certain cases, the mother is 
exposed by delivery at term, or to save the life of the child which 
might otherwise be endangered. Hence the operation may be indi- 
cated either on account of the mother alone, or of the child alone, or, 
as not unfrequently happens, of both together. 



436 OBSTETRIC OPERATIONS. 

Defective Proportion hetween the Child and Pelvis is the most Fre- 
quent Indication. — In by far the largest number of cases the operation 
is performed on account of defective proportion between the child 
and the maternal passages, due to some abnormal condition on the 
part of the mother. This want of proportion may depend on the 
presence of tumors either of the uterus or growing from the pelvis. 
But most frequently it arises from deformity of the pelvis (p. 383), 
and it is needless to repeat what has been said on that point. I 
shall, therefore, only briefly refer to a few more uncommon causes, 
which occasionally necessitate its performance. 

Habitually Large Size of the Foetal Head. — One of these is an habit- 
ually large, or over-flrmly ossified, foetal head. Should we meet 
with a case in which the labors are always extremely difficult, and 
the head apparently of unusual size, although there is no apparent 
want of space in the pelvis, the induction of labor would be perfectly 
justifiable, and in all probability would accomplish the desired ob- 
ject. In such cases the full period of delivery would require to be 
anticipated by a very short time. A week or a fortnight might 
make all the difference between a labor of extreme severity, and one 
of comparative ease. 

Condition of the Mother's Health calling for the Operation. — There 
is a large class of cases in which the condition of the mother indi- 
cates the operation. Many of these have already been considered 
when treating of the diseases of pregnancy. Amongst them may be 
mentioned vomiting which has resisted all treatment, and which has 
produced a state of exhaustion threatening to prove fatal; chorea, 
albuminuria, convulsions, or mania ; excessive anasarca, ascites, or 
dyspnoea connected with disease of the heart, lungs, or liver, may be, 
in a great measure, caused by the pressure of the enlarged uterus ; 
in fact, any condition or disease affecting the mother, provided only 
we are convinced that the termination of pregnancy would give the 
patient relief, and that its continuance would involve serious danger. 
It need hardly be pointed out that the induction of labor for any 
such causes involves grave responsibility, and is decidedly open to 
abuse; no practitioner would, therefore, be justified in resorting to 
it, especially if the child have not reached a viable age, without the 
most anxious consideration. No general rules can be laid down. 
Each case must be treated on its own merits. It is obvious that t he- 
nearer the patient is to the full period, the greater will be the chance 
of the child surviving, and the less hesitation need then be felt in 
consulting the interests of the mother. 

Conditions affecting the Safety of the Child alone. — In another class 
of cases the operation is indicated by circumstances affecting the life 
of the child alone. Of these the most common are those in which 
the child dies, in several successive pregnancies, before the termina- 
tion of utero-gestation. This is generally the result of fatty, calcare- 
ous, or syphilitic degeneration of the placenta, which is thus rendered 
incapable of performing its functions. These changes in the placenta 
seldom commence until a comparatively advanced period of preg- 
nancy; so that if labor be somewhat hastened, we may hope to 



INDUCTION OF PREMATURE LABOR. 437 

enable the patient to give birth to a living and healthy child. The 
experience of the mother will indicate the period at which the death 
of the foetus has formerly taken place, as she would then have appre- 
ciated a difference in her sensations, a diminution in the vigor of the 
foetal movements, a sense of weight and coldness, and similar signs. 
For some weeks before the time at which this change has been expe- 
rienced, we should carefully auscultate the foetal heart from day to 
day, and, in most cases, the approach of danger will be indicated 
sufficiently soon to enable us to interfere with success, by tumultuous 
and irregular pulsations, or a failure in their strength and frequency. 
On the detection of these, or on the mother feeling that the move- 
ments of the child are becoming less strong, the operation should at 
once be performed. Simpson also induced premature labor with 
success in a patient who twice gave birth to hydrocephalic children. 
In the third pregnancy, which he terminated before the natural 
period, the child was well-formed and healthy. 

Induction of Labor when the Mother is mortally 111. — Some obstetri- 
cians have proposed to induce labor, with the view of saving the 
child, when the mother was suffering from mortal disease. This 
indication is, however, so extremely doubtful, from a moral point of 
view, that it can hardly be considered as ever justifiable. 

Various Methods of Inducing Labor ; their mode of Action. — The 
means adopted for the induction of labor are very numerous. Some 
of them act through the maternal circulation, as the administration 
of ergot, and other oxytocics; others by their power of exciting reflex 
action, or by interfering with the integrity of the ovum, or by a com- 
bination of both, as the vaginal douche separation of the membranes 
from the uterine walls, puncture of the ovum, dilatation of the os, 
stimulating enemata, or irritation of the breasts. The former class 
are never employed in modern obstetric practice. Of the latter, some 
offer special advantages in particular cases, but none are equally 
adapted for all emergencies. Often a combination of more methods 
than one will be found most useful. I shall mention the various 
methods in use, and discuss brief! v the relative advantages and dis- 
advantages of each. 

Puncture of Membranes. — The evacuation of the liquor amnii, by 
the puncture of the membranes, was the first method practised, and 
was that recommended by Denman and all the earlier writers. It is 
the most certain which can be employed, as it never fails, sooner or 
later, to induce uterine contractions. There are, however, several 
disadvantages connected with it, which are sufficient to contra-indi- 
cate its use in the majority of cases. It is uncertain as regards the 
time taken in producing the desired effect, pains sometimes coming 
on within a few hours, but occasionally not until several days have 
elapsed. The contracting walls of the uterus press directly on the 
body of the child, which, being frail and immature, is less able to 
bear the pressure than at the full period of pregnancy. Hence it 
involves great risk to the foetus. Besides, the escape of the water 
does away with the fluid wedge so useful in dilating the os, and 
should version be necessary from mal-presentation — a complication 



438 OBSTETRIC OPERATIONS. 

more likely to occur than in natural labor — the operation would 
have to be performed under very unfavorable conditions. These 
objections are sufficient to justify the ordinary opinion that this pro- 
cedure should not be adopted, unless other means had been tried and 
failed. Every now and then cases are met with in which it is ex- 
tremely difficult to arouse the uterus to action, and, under such 
circumstances, in spite of its drawbacks, this method will be found 
to be very valuable. When the operation has to be performed before 
the child is viable, that is, before the seventh month, these objections 
do not hold, and then it is the simplest and readiest procedure we 
can adopt. Indeed, in producing early abortion, no other is prac- 
ticable. The operation itself is most simple, requiring only a quill, 
stiletted catheter, or other suitable instrument, to be passed up to 
the os, carefully guarded by the fingers of the left hand previously 
introduced, and to be pressed against the membranes until perfora- 
tion is accomplished. Meissner, of Leipsic, has proposed, as a modi- 
fication of this plan, that the membranes should be punctured 
obliquely, three or four inches above the os, so as to admit of a 
gradual and partial escape of the amniotic fluid, thus lessening the 
risk to the child from pressure by the uterus. For this purpose he 
employed a curved silver canuia, containing a small trocar, which 
can be projected after introduction. The risk of injuring the uterus 
by such an instrument would be considerable, and we have other 
and better means at our command which render it unnecessary. 
When we require to produce early abortion, it would be well not to 
attempt to puncture the membranes with a sharp-pointed instrument. 
The object can be effected with equal certainty, and greater safety, 
by passing an ordinary uterine sound through the os, and turning it 
round once or twice. 

Administration of Oxytocics. — The administration of ergot of rj r e, 
either alone, or combined with borax and cinnamon, has been some- 
times resorted to. . This practice has been principally advocated by 
Eamsbotham, who was in the habit of exhibiting scruple doses of 
the powdered ergot every fourth hour, until delivery took place. 
Sometimes he found that as many as thirty or forty doses were re- 
quired to effect the object ; occasionally labor commenced after a 
single dose. Finding that the infantile mortality was very great 
when this method was followed, he modified it, and administered 
two or three doses only, and, if these proved insufficient, he punc- 
tured the membranes. There can be no doubt that ergot possesses 
the power of inducing uterine contractions. The risk to the child 
is, however, quite as great as when the membranes are punctured ; 
for not only is it subject to injurious pressure from the tumultuous 
and irregular contractions which the ergot produces, but the drug 
itself, when given in large doses, seems to exert a poisonous influence 
on the foetus. For these reasons ergot may properly be excluded 
from the available means of inducing labor. 

Methods acting Indirectly on the Uterus. — Various methods have 
been recommended which act indirectly on the uterus, the source of 
irritation being at a distance. Thus D'Outrepont used frequently 



INDUCTION OF PREMATURE LABOR 



439 



repeated abdominal frictions and tight bandages. Scanzoni, remem- 
bering the intimate connection between the mammas and uterus, and 
the tendency which irritation of the former has to induce contraction- 
of the latter, recommended the frequent application of cupping- 
glasses to the breasts. Eadforcl and others have employed galvanism. 
Stimulating enemata have been employed. All these methods have 
occasionally proved successful, and, unlike the former plans we have 
mentioned, they are not attended by any special risk to the child. 
They are, however, much too uncertain to be relied on, besides being- 
irksome both to the patient and practitioner. 

The artificial dilatation of the os uteri, in imitation of its natural 
opening in labor, was first practised by Kliige. He was in the habit 
of passing within the os a tent made of compressed sponge, and 
allowing it to dilate by imbibition of fluid. If labor were not pro- 
voked within twenty-four hours he removed it, and introduced one 
of larger dimensions, changing it as often as was necessary until his 
object was accomplished. Although this operation seldom failed to 
induce labor, it had the disadvantage of occupying an indefinite time, 
and the irritation produced was often painful and annoying. Dr. 
Keiller, of Edinburgh, was the first to suggest the Use of caoutchouc 
bags, distended by air, as a means of dilating the os. This plan has 
been perfected by Dr. Barnes in his well-known dilators, which are 
of great use in many cases in which artificial dilatation of the cervix 
is necessary. They consist of a series of india-rubber bags of various 
sizes, with a tube attached (Fig. 141), through which 
water can be injected by an ordinary Higginson's 
syringe. They have a small pouch fixed externally, 
in which a sound can be placed, so as to facilitate 
their introduction. When distended with water the 
bags assume somewhat of a fiddle shape, bulging at 
both extremities, which insures their being retained 
within the os. When first introduced into practice 
as a means of inducing labor, it was thought that 
this method gave a complete control over the pro- 
cess, so that it could be concluded within a definite 
time at the will of the operator. The experience of 
those who have used it much has certainly not justi- 
fied this anticipation. It is true that, occasionally, 
contractions supervene within a few hours after dila- 
tation has been commenced; but, on the other hand, 
the uterus often responds very imperfectly to this 
kind of stimulus, and the bags may be inserted for 
many consecutive hours without the desired result supervening ; the 
puncture of the membranes being eventually necessary in order to 
hasten the process. Indeed, my own experience would lead me to 
the conclusion that, as a means of evoking uterine contraction, cervi- 
cal dilatation is very unsatisfactory. Dr. Barnes himself has evi- 
dently seen reason to modify his original views, for, while he at first 
talked of the bags as enabling us to induce labor with certainty at a 
given time, he has since recommended that uterine action should be 



Fig. 141. 




Barnes's Bag for 
Dilating the Cervix. 



440 OBSTETRIC OPERATIONS. 

first provoked by other means, the dilators being subsequently used 
to accelerate the labor thus brought on. The bags thus employed 
find, as I believe, their most useful and a verj r valuable application; 
but when used in this way they cannot be considered a means of 
originating uterine action. A subsidiary objection to the bags is the 
risk of displacing the presenting part. I have, for example, intro- 
duced them when the head was presenting, and, on their removal, 
found the shoulder lying over the os. It is not difficult to understand 
how the continuous pressure of a distended bag in the internal os 
might easily push away the head, which is so readily movable as 
long as the membranes are unruptured. Still, if labor be in progress, 
and the os insufficiently dilated, the possibilit}^ of this occurrence is 
not a sufficient reason for not availing ourselves of the undoubtedly 
valuable assistance which the dilators are capable of giving. 

Separation of the Membranes. — Some processes for inducing labor 
act directly on the ovum, by separating the membranes, to a greater 
or less extent, from the uterine Avails. The first procedure of the 
kind was recommended by Dr. Hamilton, of Edinburgh, and con- 
sisted in the gradual separation of the membranes for one or two 
inches all round the lower segment of the uterus. To reach them, 
the finger had to be gently insinuated into the interior of the os, 
which was gradually dilated to a sufficient extent by a series of suc- 
cessive operations, repeated at intervals of three or four hours. 
When this had been accomplished, the fore-finger was inserted and 
swept round between the membranes and the uterus, but it was fre- 
quently found necessary to introduce the greater part of the hand to 
effect the object, and, sometimes, even this was not sufficient, and a 
female catheter or other instrument had to be used for the purpose. 
The method was generally successful in bringing on labor, but it now 
and then failed, even in Dr. Hamilton's hands. It is certainly based 
on correct principles, but it is tedious and painful both to the prac- 
titioner and the patient, and very uncertain in its time of action. 
For these reasons it has never been much practised. 

Vaginal and Uterine Douches. — In the year 1836 Kiwisch suggested 
a plan which, from its simplicity, has met with much approval. It 
consists in projecting, at intervals, a stream of warm or cold water 
against the os uteri. Its action is doubtless complex. Kiwisch him- 
self believed that relaxation of the soft parts, through the imbibition 
of water, was the determining cause of labor. Simpson found that 
the method failed, unless the water mechanically separated the mem- 
branes from the uterine Avails. Besides this effect, it probably di- 
rectly induces reflex action, by distending the vagina and dilating the 
os. In using it, it has been customary to administer a douche tAvice 
daily, and more frequently if rapid effects be desired. The number 
required varies in different cases. The largest number KiAvisch 
found it necessary to use was 17, the smallest 4. The average time 
that elapses before labor sets in is four days. Hence the method is 
obviously useless when rapid delivery is required. 

Dr. Cohen, of Hamburgh, introduced an important modification of 
the process, which has been considerably practised. It consists in 



INDUCTION OF PREMATURE LABOR. 441 

passing a silver or gum-elastic catheter some inches within the os, 
between the membranes and the uterine walls, and injecting the fluid 
through it directly into the cavity of the uterus. He used creosote, 
or tar- water, and injected, without stopping, until the patient com- 
plained of a feeling of distension. Others have found the plan 
equally efficacious when they only employed a small quantity of 
plain water, such as 7 or 8 ounces. Professor Lazarewitch, of Char- 
koff, is a strong advocate of this method. He believes that uterine 
action is evoked much more rapidly and certainly if the water be 
injected near the fundus, and he has contrived an instrument for the 
purpose, with a long metallic nozzle. 

Dangers of these Plans. — So many fatal cases have followed these 
methods, that it cannot be doubted that, in spite of their certainty 
and simplicity, there is an element of risk in them which should not 
be overlooked. Many of these are recorded in Barnes's work, and 
he comes to the conclusion, which the facts unquestionably justify, 
that " the douche, whether vaginal or intra-uterine, ought to be ab- 
solutely condemned as a means of inducing labor." The precise rea- 
son of the clanger is not yqtj obvious. Sudden stretching of the 
uterine walls, producing shock, has been supposed to have caused it; 
but in many of the fatal cases the symptoms have been rather those 
attending the passage of air into the veins, and it is easy to under- 
stand how air may have been introduced, in this way, into the large 
uterine sinuses. 

Injection of Carbonic Acid Gas. — Simpson and Scanzoni have both 
tried with success the injection of carbonic acid gas into the vagina. 
Fatal results have, however, followed its employment, and Simpson 
has expressed an opinion that the experiment should not be re- 
peated. 

Simpson's Method of Operating. — Simpson originally induced labor 
bv passing the uterine sound within the os, and up towards the fun- 
dus, and, when it had been inserted to a sufficient extent, moving it 
slightly from side to side. He was led to adopt this procedure m 
the belief that we might thus closely imitate the separation of the 
deciclua, which occurs previous to labor at term. Uterine contrac- 
tions were induced with certainty and ease, but it was found impossi- 
ble to foretell what time might elapse between the commencement of 

j labor and the operation, which had frequently to be performed more 
than once. He subsequently modified this procedure by introducing 

) a flexible male catheter, without a stilette, which he allowed to re- 
main in the uterus until contractions were excited. This plan is 

1 much used in Germany, and is now that which is also most fre- 
quently adopted in this country. It is simple and very efficacious,, 
pains coming on, almost invariably, within 24 hours after the cathe- 
ter or bougie is introduced. A theoretical objection is the possi- 

\ bility of the catheter separating a portion of the placenta and giving 

I rise to hemorrhage ; but in practice this has not been found to occur, 

and the risk might generally be avoided by introducing the catheter 

at a distance from the placenta, the probable situation of which has 

been ascertained by auscultation. The more deeply the catheter is 

29 



442 OBSTETRIC OPERATIONS. 

introduced, the more certain and rapid is its effect, and not less than 
7 inches should be pushed up within the os. It is not always easy 
to insert it so far, especially if a flexible catheter be used, which is 
apt to be too pliable to pass upwards with ease. A solid bougie — 
male urethral bougie — should, therefore, be employed, and I have 
found its introduction greatly facilitated by anaesthetising the patient, 
and passing the greater part of the hand into the vagina. In this 
way it can be pushed in very gently, and without any risk of injury 
to the uterus. There is some chance of rupturing the membranes 
while pushing it upwards. This accident, indeed, cannot always be 
avoided, even when the greatest care is taken ; but, when it occurs, 
the puncture will be at a distance from the os, so that a small portion 
only of the liquor amnii will escape, and this can scarcely be con- 
sidered a serious objection. It is always an advantage to allow the 
pains to come on gradually, and in imitation of natural labor. There- 
fore, if, after the bougie has been inserted for a sufficient time, uterine 
contractions come on sufficiently strongly, we may leave the case to 
be terminated naturally ; or, if they be comparatively feeble, we may 
resort to accelerative procedures, viz., dilatation of the cervix by the 
fluid bags, and subsequently the puncture of the membranes. In 
this way we have the labor completely under control ; and I believe 
this method will commend itself to those who have experience of it, 
as the simplest and most certain mode of inducing labor yet known, 
and the one most closely imitating the natural process. 

The Child is Immature and Difficult to Rear. — It should not be for- 
gotten that the child is immature, and that unusual care is likely to 
be required to rear it successfully. We should, therefore, be careful 
to have at hand all the usual means of resuscitation; and, as the 
mother may not be able to nurse at once, it would be a good pre- 
caution to have a healthy wet nurse in readiness. 



CHAPTEE II. 

TURNING. 



Turning, by which we mean the alteration of the position of the 
foetus, and the substitution of some other portion of the body for 
that originally presenting, is one of the most important of obstetric 
operations, and merits careful study. It is also one of the most 
ancient, and was evidently known to the Greek and Eoman physi- 
cians. Up to the fifteenth century, cephalic version — that in which 
the head of the foetus is brought over the os uteri — was almost 
exclusively practised, when Pare and his pupil Guillemeau taught 
the propriety of bringing the feet down first. It was by the latter 



TURNING. 443 

physician especially that the steps of the operation were clearty 
defined; and the French have undoubtedly the merit both of per- 
fecting its performance, and of establishing the indications which 
should lead to its use. Indeed, it was then much more frequently 
performed than in later times, since no other means of effecting arti- 
ficial delivery were known, which did not involve the death of the 
child; and practitioners, doubtless, acquired great skill in its per- 
formance, and were inclined to overrate its importance, and extend 
its use to unsuitable cases. An opposite error was fallen into after 
the invention of the forceps, which for a time led to the abandonment 
of turning in certain conditions for which it was well adapted, and 
in which it has only of late years been again practised. 

Cephalic version has, since Pare wrote, been recommended and 
practised from time to time, but the difficulty of performing it satis- 
factorily was so great that it never became an established operation. 
Dr. Braxton Hicks has perfected a method by which it can be ac- 
complished with greater ease and certainty, and which renders it a 
legitimate and satisfactory resort in suitable cases. To him we are 
also indebted for introducing a method of turning without passing 
the entire hand into the cavity of the uterus, which, under favorable 
circumstances, is not only easy of performance, but deprives the 
operation of one of its greatest dangers. 

Turning by External and Internal Manipulation. — The possibility 
of effecting version by external manipulation has been long known, 
and was distinctly referred to and recommended by Dr. John Pechey, 1 
so far back as the year 1698. Since that time it has been strongly 
advocated by Wigand and his followers ; and various authors in this 
country, notably Sir James Simpson, have referred to the advantage 
to be derived from external manipulation assisting the hand in the 
interior of the uterus. To Dr. Hicks, however, incontestably belongs 
the merit of having been the first distinctly to show the possibility 
of effecting complete version by combined external and internal mani- 
pulation, of laying down definite rules for its practice, and of thus 
popularizing one of the greatest improvements in modern midwifery. 

Object and Nature of the Operation.— -The operation is entirely 
dependent for success on the fact that the child in utero is freely 
movable, and that its position may be artificially altered with 
facility. As long as the membranes are unruptured, and the foetus 
is floating in the surrounding fluid medium, it is liable to constant 
changes in position, as may be readily demonstrated in the latter 
months of pregnancy ; and the operation, under these circumstances, 
may be performed with the greatest facility. Shortly after the liquor 
amnii has escaped there is still, as a rule, no great difficulty in effect- 
ing version ; but, as the body is no longer floating in the surround- 
ing liquid, its rotation must necessarily be attended with some 
increased risk of injury to the uterus. If the liquor amnii have 
been long evacuated, and the muscular structure of the uterus be 
strongly contracted, the foetus may be so firmly fixed, that any 

1 The Complete Midwife's Practice, p. 142. 



444 OBSTETRIC OPERATIONS. 

attempt to move it is surrounded with, the greatest difficulties, and 
may even fail entirely, or be attended with such risks to the maternal 
structures as to be quite unjustifiable. 

Cases Suitable for the Operation. — Version may be required either 
on account of the mother or child alone ; or it may be indicated by 
some condition imperilling both, and rendering immediate delivery 
necessary. The chief cases in which it is resorted to are those of 
transverse presentation, where it is absolutely essential ; accidental 
or unavoidable hemorrhage ; certain cases of contracted pelvis; and 
some complications, especially prolapse of the funis. The special 
indications for the operation have been separately discussed under 
these subjects. 

Statistics and Dangers of the Operation. — The ordinary statistical 
tables cannot be depended on as giving any reliable results as to the 
risks of the operation. Taking all cases together, Dr. Churchill esti- 
mates the maternal mortality as 1 in 16, and the infantile as 1 in 3. 
Like all similar statistics, they are open to the objection of not dis- 
tinguishing between the results of the operation itself, and of the 
cause which necessitated interference. Still they are sufficient to 
show that the operation is not free from grave hazards, and that it 
must not be undertaken without due reflection. The principal 
dangers will be discussed as we proceed. It may suffice to mention 
here that those to the mother must vary with the period at which 
the operation is undertaken. If version be performed early, before 
the rupture of the membranes, or, in favorable cases, without the 
introduction of the hand into the interior of the uterus, the risk 
must of course be infinitely less than in those more formidable cases 
in which the waters have long escaped, and the hand and arm have 
to be passed into an irritable and contracted uterus. But even in 
the most unfavorable cases accidents may be avoided, if the operator 
bear constantly in mind that the principal danger consists in lace- 
ration of the uterus or vagina from undue force being employed, or 
from the hand and arm not being introduced in the axis of the pas- 
sages. There is no operation in which gentleness, absence of all 
hurry, and complete presence of mind are so essential. A certain 
number of cases end fatally from shock or exhaustion, or from sub- 
sequent complications. As regards the child, the mortality is little, 
if at all, greater than in original breech and footliug presentations. 
Nor is there any good reason why it should be so, seeing that cases 
of turning, after the feet are brought through the os, are virtually 
reduced to those of feet presentation, and that the mere version, if 
effected sufficiently soon, is not likely to add materially to the risk 
to which the child is exposed. 

Version by External Manipulation. — The possibility of effecting 
version by external manipulation has been recognized by various 
authors, and was made the subject of an excellent thesis by Wigand, 
who clearly described the manner of performing the operation. In 
spite of the manifest advantages of the procedure, and the extreme 
facility with which it can be accomplished in suitable cases, it has 
by no means become the established custom to trust to it, and prob- 



TURNING. 445 

ably most practitioners have never attempted it, even under the most 
favorable conditions. The possibility of operation is based on the 
extreme mobility of the foetus before the membranes are ruptured. 
After the waters have escaped, the uterine walls embrace the foetus 
more or less closely, and version can no longer be readily performed 
in this manner. 

Cases suitable for the Operation. — It may, therefore, be laid down 
as a rule that it should only be attempted when the abnormal posi- 
tion of the foetus is detected before labor has commenced, or in the 
early stage of labor, when the membranes are unruptured. It is 
also unsuitable for any but transverse presentations, for it is not 
meant to effect complete evolution of the foetus, but only to substi- 
tute the head for the upper extremity. It is useless whenever rapid 
delivery is indicated, for, after the head is brought over the brim, 
the conclusion of the case must be left to the natural powers. 

Method of Performance. — The manner of detecting the presentation 
by palpation has been already described (p. 114), and the success of 
the operation depends on our being able to ascertain the positions of 
the head and breech through the uterine walls. Should labor have 
commenced, and the os be dilated, the transverse presentation may be 
also made out by vaginal examination. Should the abnormal pre- 
sentation be detected before labor has actually begun, it is, in most 
cases, easy enough to alter it, and to bring the foetus into the longi- 
tudinal axis of the uterine cavity. It is seldom, however, discovered 
until labor has commenced, and, even if it be altered, the child is ex- 
tremely apt to reassume, in a short time, the faulty position in which 
it was formerly lying- Still there can be no harm in making the 
attempt, since the operation itself is in no way painful, and is abso- 
lutely without risk either to the mother or child. When the trans- 
verse presentation is detected early in labor, I believe it is good 
practice to endeavor to remedy it by external manipulation, and, if 
it fail, we may at once proceed to other and more certain methods 
of operating. The procedure itself is abundantly simple. The pa- 
tient is placed on her back, and the position of the foetus ascertained 
by palpation as accurately as possible, in the manner already indi- 
cated. The palms of the hands being then placed over the opposite 
poles of the foetus, by a series of gentle gliding movements, the head 
is pushed towards the pelvic brim, while the breech is moved in the 
opposite direction. The facility with which the foetus may some- 
times be moved in this way can hardly be appreciated by those who 
have never attempted the operation. As soon as the change is 
effected, the long diameters of the foetus and of the uterus will cor- 
respond, and vaginal examination will show that the shoulder is no 
longer presenting, and that the head is over the pelvic brim. If 
the os be sufficiently dilated, and labor in progress, the membranes 
should now be punctured, and the position of the foetus maintained 
for a short time by external pressure, until we are certain that the 
cephalic presentation is permanently established. If labor be not in 
progress, an attempt may at least be made to effect the same object 
by pads and a binder; one pad being placed on the side of the uterus 



446 OBSTETRIC OPERATIONS. 

in the situation of the breech, and another on the opposite side in 
the situation of the head. 

Cephalic Version. — On account of the difficulty of performing cepha- 
lic version in the manner usually recommended, it has practically 
scarcely been attempted, and, with the exception of some more recent 
authors, it is generally condemned by writers on systematic mid- 
wifery. Still the operation offers unquestionable advantages in those 
transverse presentations in which rapid delivery is not necessary, 
and in which the only object of interference is the rectification of 
malposition; for, if successful, the child is spared the risk of being 
drawn footling through the pelvis. The objections to cephalic ver- 
sion are based entirely on the difficulty of performance; and, un- 
doubtedly, to introduce the hand within the uterus, search for, seize, 
and afterwards place the slippery head in the brim of the pelvis, 
could not be an easy process, even under the most favorable circum- 
stances, and must always be attended by considerable risk to the 
mother. Yelpeau, who strongly advocated the operation, w T as of 
opinion that it might be more easily accomplished by pushing up the 
presenting part, than by seizing and bringing down the head. Wi- 
gand more distinctly pointed out that the head could be brought to 
a proper position by external manipulation, aided by the fingers of 
one hand within the vagina. Braxton Hicks has laid down clear 
rules for its performance, which render cephalic version easy to ac- 
complish under favorable conditions, and will doubtless cause it to 
become a recognized mode of treating malpositions. The number of 
cases, however, in which it can be performed must always be .limited, 
since, as in turning by external manipulation alone, it is necessary 
that the liquor amnii should be still retained, or at least have only 
recently escaped ; that the presentation be freely movable above the 
pelvic brim ; and that there be no necessity for rapid delivery. Dr. 
Hicks does not believe protrusion of the arm to be a contra-indica- 
tion, and advises that it should be carefully replaced within the 
uterus. When, however, protrusion of the arm has occurred, the 
thorax is so constantly pushed down into the pelvis that replacement 
can neither be safe nor practicable, except under unusually favorable 
conditions, and podalic version will be necessary. 

Method of Performance. — It is impossible to describe the method 
of performing cephalic version more concisely and clearly than in 
Dr. Hicks's own words. "Introduce," he says, "the left hand into 
the vagina, as in podalic version; place the right hand on the out- 
side of the abdomen, in order to make out the position of the foetus, 
and the direction of its head and feet. Should the shoulder, for 
instance, present, then push it with one or two fingers in the direc- 
tion of the feet. At the same time pressure with the other hand 
should be exerted on the cephalic end of the child. This will bring 
the head clown to the os; then let the head be received on the tips 
of the inside lingers. The head will play like a ball between the 
two hands; it will be under their command, and can be placed in 
almost any part at will. Let the head then be placed over the os, 
taking care to rectify any tendency to face presentation. It is as 



TUBNING. 417 

well, if the breech, will not rise to the fundus readily after the head 
is fairly in the os, to withdraw the hand from the vagina, and with 
it press up the breech from the exterior. The hand which is re- 
taining gently the head from the outside should continue there for 
some little time, till the pains have insured the retention of the child 
in its new position and the adaptation of the uterine walls to its new 
form. Should the membranes be perfect, it is advisable to rupture 
them as soon as the head is at the os uteri; during their flow and 
after the head will move easily into its proper position." 

The procedure thus described is so simple, and would occupy so 
short a time, that there can be no objection to trying it. Should we 
fail in our endeavors, we shall not be in a worse position for effecting 
delivery by podalic version, which can be proceeded with without 
withdrawing the hand from the vagina, or in any way altering the 
position of the patient. 

Podalic Version. — The method of performing podalic version varies 
with the nature of each particular case. In describing the operation, 
it has been usual to divide the cases into those in which the circum- 
stances are favorable, and the necessary manoeuvres easily accom- 
plished; and those in which there are likely to be considerable diffi- 
culties, and increased risk to the mother. This division is eminently 
practicable, since nothing can be more variable than the circum- 
stances under which version may be required. Before describing 
the steps of the operation, it may be well to consider some general 
conditions applicable to all cases alike. 

Position of the Patient. — In this country the ordinary position on 
the left side is usually employed. On the Continent and in America 
the patient is placed on her back, with the legs supported by assist- 
ants, as in lithotomy. The former position is preferable, not only 
as a matter of custom, and as involving much less fuss and exposure 
of the person, but because it admits of both the operator's hands 
being more easily used in concert. In certain difficult cases, when 
the liquor amnii has escaped, and the back of the child is turned 
towards the spine of the mother, the dorsal decubitis presents some 
advantages in enabling the hand to pass more readily over the body 
of the child ; but such cases are comparatively rare. The patient 
should be brought to the side of the bed, across which she should 
be laid, with the hips projecting over, and parallel to, the edge, the 
knees being flexed towards the abdomen, and separated from each 
other by a pillow, or by an assistant. Assistants should also be 
placed so as to restrain the patient if necessary, and prevent her 
involuntarily starting from the operator, as this might not only 
embarrass his movements, but be the cause of serious injury. 

Administration of Anaesthetics. — The exhibition of anaesthetics is 
peculiarly advantageous. There is nothing which tends to facilitate 
the steps of the process so much as stillness on the part of the 
patient, and the absence of strong uterine contraction. YThen the 
vagina is very irritable and the uterus firmly contracted round the 
body of the child, complete amesthesia may enable us to effect ver- 
sion, when without it we should certainly fail. 



448 OBSTETRIC OPERATIONS. 

Period when the Operation should he Undertaken. — The most favor- 
able time for operating is when the os is fully dilated, before, or im- 
mediately after, the rupture of the membranes and the discharge of 
the liquor amnii. The advantage gained by operating before the 
waters have escaped cannot be overstated, since we can then make 
the child rotate with great facility in the fluid medium in which it 
floats. In the ordinary operation, in which the hand is passed into 
the uterus, it is essential to wait until the os is of sufficient size to 
admit its being introduced with safety. This may generally be done 
when the os is the size of a crown-piece, especially if it be soft and 
yielding. 

Choice of Hand to he used. — The practice followed with regard to 
the hand to be used in turning varies considerably. Some accoucheurs 
always employ the right hand, others the left, and some one or other, 
according to the position of the child. In favor of the right hand, 
it is said that most practitioners have more power with it, and are 
able to use it with greater gentleness and delicacy. In transverse 
presentations, if the abdomen of the child be placed anteriorly, the 
right hand is said to be the proper one to use, on account of the 
greater facility with which it can be passed over the front of the 
child ; and in difficult cases of this kind, when we are operating with 
the patient on her back, it certainly can be employed with more pre- 
cision than the left. In all ordinary cases, however, the left hand 
can be introduced much more easily in the axis of the passages, the 
back of the hand adapts itself readily to the curve of the sacrum, 
and, even when the child's abdomen lies anteriorly, it can be passed 
forwards without difficulty so as to seize the feet. These advantages 
are sufficient to recommend its use, and very little practice is re- 
quired to enable the practitioner to manipulate with it as freely as 
with the right. If, in addition, we remember that the right hand is 
required to operate on the foetus through the abdominal walls — and 
this is a point which should never be forgotten — we shall have 
abundant reasons for laying it down as a rule that the left hand 
should generally be employed. Before passing the hand and arm 
they should be freely lubricated, with the exception of the palm, 
which is left untouched to admit of a firm grasp being taken of the 
foetal limbs. It is also advisable to remove the coat, and bare the 
arm as high as the elbow. 

As it should be a cardinal rule to resort to the simplest procedure 
when practicable, it will be well to consider first the method by com- 
bined external and internal manipulation, without passing the hand 
into the uterus, and subsequently that which involves the introduc- 
tion of the hand. 

Turning by Combined External and Internal Manipulation. — To 
effect podalic version by the combined method it is an essential pre- 
liminary to ascertain the situation of the foetus as accurately as pos- 
sible. It will generally be easy, in transverse presentation, to make 
out the breech and the head by palpation ; while, in head presenta- 
tions, the fontanel! es will show to which side of the pelvis the face 
is turned. The left hand is then to be passed carefully into the 



TURNING 



449 



vagina, in the axis of the canal, to a sufficient extent to admit of the 
fingers passing freely into the cervix. To effect this, it is not always 
necessary to insert the whole hand, three or four fingers being gen- 
erally sufficient. 

If the head lie in the first or fourth position, push it upwards and 
to the left ; while the other hand, placed externally on the abdomen, 



Fig. 142. 




First Stage of Bi-polar Version. — Elevation of the Head and Depression of the Breech. 

(After Barnes.) 

depresses the breech towards the right (Fig. 143). By this means 
we act simultaneously on both extremities of the child's body, and 
easily alter its position. The breech is pushed down gently but 
firmly, by gliding the hand over the abdominal wall. The head will 
now pass oat of reach, and the shoulder will arrive at the os, and 
will lie on the tips of the fingers. This is similarly pushed upwards 
in the same direction as the head (Fig. 143), the breech at the same 
time being still further depressed, until the knee comes within reach 
of the fingers, when (the membranes being now ruptured, if still 
unbroken) it is seized and pulled down through the os (Fig. 144). 
Occasionally the foot comes immediately over the os, when it can be 
seized instead of the knee. Version may be facilitated by changing 
the position of the external hand, and pushing the head upwards 
from the iliac fossa, instead of continuing the attempt to depress the 
breech (Figs. 144 and 145). These manipulations should always be 
carried on in the intervals, and desisted from when the pains come 



450 



OBSTETRIC OPERATIONS. 



on ; and when the pains recur with great force and frequency, the 
advantage of chloroform will be particularly apparent. In the | 



Fig. 143. 




Second Stage of Bi-polar Version. — Elevation of the shoulders and depression of the breech. 

(After Barnes.) 

second and third positions, the steps of the operation should be re- 
versed; the head is pushed upwards and to the right, the breech 

Fig. 144. 




Third Stage of Bi-polar Version. — Seizure of the knee and partial elevation of the head. 

(After Barnes.) 

downwards and to the left. When the position cannot be made out 
with certainty, it is well to assume that it is the first, since that is 



TURNING. 



451 



the one most frequently met with ; and even if it be not, no great 
inconvenience is likely to occur. If the os be not sufficiently open 
to admit of delivery being concluded, the lower extremity can be 
retained in its new position with one finger, until dilatation is suffi- 



Fig. 145. 




Fourth Stage of Bi-polar Version. 



•Drawing down of leg and completion of version. 
Barnes.) 



(After 



ciently advanced, or until the uterus has permanently adapted itself 
to the altered position of the child, either of which results will gene- 
rally be effected in a short space of time. 

In transverse presentations the same means are to be adopted, the 
shoulder being pushed upwards in the direction of the head, while 
the breech is depressed from without. This is frequently sufficient 
to bring the knees within reach, especially if the membranes are 
entire, but version is much facilitated by pressing the head upwards 
from without, alternately with depression of the breech. If the 
liquor amnii has escaped, and the uterus is firmly contracted round 
the body of the child, it will be found impossible to effect an altera- 
tion in its position without the introduction of the hand, and the 
ordinary method of turning must be employed. The peculiar advan- 
tage of the combined process is, that it in no way interferes with 
the latter, for, should it not succeed, the hand can be passed on into 
the uterus without Avithdrawal from the vagina (provided the os be 
sufficiently dilated), and the feet or knees seized and brought down. 

Podalic Version v;hen the Hand is Introduced into theUterus. — Turn- 
ing, with the hand introduced into the 



uterus, provided" the waters 



452 OBSTETRIC OPERATIONS. 

have not or have only recently escaped, and the os be sufficiently 
dilated, is an operation generally performed with ease. 

Introduction of the Hand. — The first step, and one of the most 
important, is the introduction of the hand and arm. The fingers 
having been pressed together in the form of a cone, the thnmb tying 
between the rest of the fingers, the hand, thus reduced to the smallest 
possible dimensions, is slowly and carefully passed into the vagina, 
in the axis of the outlet, in an interval between the pains, and passed 
onwards in the same cautious manner, and with a semi-rotatory 
motion, until it lies entirely within the vagina, the direction of intro- 
duction being gradually changed from the axis of the outlet to that 
of the brim. If uterine contractions come on, the hand should 
remain passive until they are over. It should ever be borne in 
mind, as one of the fundamental rules in performing version, that 
we should act only in the absence of pains, and then with the utmost 
gentleness — all force and violent pushing being avoided. The hand, 
still in the form of a cone, having arrived at the os, if this be suffi- 
ciently dilated, may be passed through at once. If the os be not 
quite open, but dilatable, the points of the fingers may be gently 
insinuated, and occasionally expanded, so as to press it open suffi- 
ciently to permit the rest of the hand to pass. While this is being 
done, the uterus should be steadied by the other hand placed exter- 
nally, or by an assistant. If the presentation should not previously 
have been made out with accuracy, we can now ascertain how to 
pass the hand onwards, so that its palmar surface may correspond 
with the abdomen of the child. 

Rupture of the Membranes. — The membranes should now be rup- 
tured — if possible during the absence of pain — so as to prevent the 
waters being forced out. The hand and arm form a most efficient 
plug, and the liquor amnii cannot escape in any quantity. Some 
practitioners recommend that, before rupturing the membranes, the 
hand should be passed onwards between them and the uterine walls, 
until we reach the feet. By so doing we run the risk of separating 
the placenta ; besides we have to introduce the hand much further 
than may be necessary, since the knees are often found lying quite 
close to the os. As soon as the membranes are perforated, the hand 
can be passed on in search of the feet (Fig. 146). At this stage of 
the operation increased care is necessary to avoid anything like 
force ; and should a pain come on, the hand must be kept perfectly 
flat and still, and rather pressed on the body of the child than on the 
uterus. If the pains be strong, much inconvenience may be felt from 
the compression; and, were the onward movement continued, or the 
hand even kept bent in the conical form in which it was introduced, 
rupture of the uterine Avails might easily be caused. This is not 
likely to occur in the class of cases now under consideration, for it 
is chiefly when the waters have long escaped that the progress of the 
hand is a matter of difficulty. Valuable assistance may now be given 
by pressing the breech downwards from without, so as to bring the 
knees or feet more easily within the reach of the internal hand. 
Having arrived at the knees or feet, they may be seized between the 



TURNING 



453 



fingers, and drawn downwards in the absence of a pain (Fig. 147). 
This will cause the foetus to revolve on its axis, the breech will de- 
scend, and, at the same time, the ascent of the head may be assisted 
bv the right hand from without. It is a question with many ac- 



Fio. 146. 




Seizure of the Feet when the Hand is Introduced into the Uterus. 

coucheurs which part of the inferior extremities should be seized 
and brought down. Some recommend us to seize both feet, others 
prefer one only, while some advise the seizure of one or both knees. 
In a simple case of turning, before the escape of the waters, it does 
not much matter which of these plans is followed, since version is 
accomplished with the greatest ease by any one of them. The seizure 
of the knee, however, instead of the feet, offers certain advantages 
which should not be overlooked. It is generally more accessible, 
affords a better hold (the fingers being inserted in the flexure of the 
ham), and, being nearer the spine, traction acts more directly on the 
body of the child. Any danger of mistaking the knee for the elbow 
may be obviated by remembering the simple rule that the salient 
angle of the former looks towards the head of the child, of the latter 
towards its feet. Certain advantages may also be gained by bring- 
ing down one foot or knee only, instead of both. When one inferior 
extremity remains flexed on the body of the child, the part which 
has to pass through the os is larger than when both legs are drawn 
down, and consequently the os is more perfectly dilated, and less 



454 



OBSTETRIC OPERATIONS 



difficulty is likely to be experienced in the delivery of the rest of the 
body, so that the risk to the child is materially diminished. 



Fig. 147. 




Drawing down of the Feet and Completion of Version. 

Choice of Leg to he brought down in Transverse Presentations. — 
Simpson, whose views have been adopted by Barnes and other writers, 
recommend the seizing, if possible, in arm presentations, of the knee 
farthest from and opposite to the presenting arm, as by this means 
the body is turned round on its longitudinal axis, and the presenting 
arm and shoulder more easily withdrawn from the os. Dr. Galabin 
has carefully investigated this point in a recent paper, 1 and contends 
that there is a greater mechanical advantage in seizing the leg which 
is nearest to, and on the same side as, the presenting arm, and this, 
moreover, is generally more readily done. 

Management of the Case after Version. — As soon as the head has 
reached the fundus, and the lower extremity is brought through the 
os, the case is converted into a foot or knee presentation, and it comes 
to be a question whether delivery should now be left to nature or 
terminated by art. This must depend to a certain extent on the case 
itself, and on the cause which necessitated version, but generally, it 



Obst. Trans., vol. xix. 187 7. 



TURNING 



455 



will be advisable to finish delivery without unnecessary delay. To 
accomplish this, downward traction is made during the pains, and 
desisted from in the intervals (Fig. 148). As the umbilical cord 



Fig. 148. 




Showing the Completion of Version. (After Bcarnes.) 

appears, a loop should be drawn down ; and if the hands be above 
the head, they must be disengaged and brought over the face, in the 
same manner as in an ordinary footling presentation. The manage- 
ment of the head, after it descends into the cavity of the pelvis, must 
also be conducted as in labors of that description. 

Turning in Placenta Prsevia. — In cases of placenta prsevia the os 
will, as a rule, be more easily dilatable than in transverse presenta- 
tions. Hicks's method offers the great advantage of enabling us to 
perform version much sooner than was formerly possible, since it 
only requires the introduction of one or two fingers into the os uteri. 
Should we not succeed by it, and the state of the patient indicates 
that delivery is necessary, we have at our command, in the fluid 
dilators, a means of artificially dilating the os uteri which can be 
employed with ease and safety. If we have to do with a case of 
■entire placental presentation, the hand should be passed at that point 
where the placenta seems to be least attached. This will alwaj^s be 
better than attempting to perforate its substance, a measure some- 
times recommended, but more easily performed in theory than in 
practice. If the placenta only partially present, the hand should, of 



456 OBSTETRIC OPERATIONS. 

course be inserted at its free border. It will frequently be advisable 
not to hasten delivery after the feet have been brought through the 
os, for they form of themselves a very efficient plug, and effectually 
prevent further loss of blood ; while, if the patient be much ex- 
hausted, she may have her strength recruited by stimulants, etc., 
before the completion of delivery. 

Turning in Ab domino -anterior Positions. — In abdomino-anterior 
positions, in which the waters have escaped, and in which, therefore, 
some difficulty may be reasonably anticipated, the operation is gener- 
ally more easily performed with the patient on her back ; the right 
hand is then introduced in the uterus, and the left employed exter- 
nally (Fig. 149). In this way the internal hand has to be passed a 

Fig. 149. 




Showing the Use of the Eight Hand in Abdomino-anterior Position. 

shorter distance, and in a less constrained position. The operator 
then sits in front of the patient, who is supported at the edge of the 
bed in the lithotomy position with the thighs separated, and the right 
hand is passed up behind the pubis, and over the abdomen of the child. 
Difficult Gases of Arm Presentation. — The difficulties of turning 
culminate in those unfavorable cases of arm presentation in which 
the membranes have been long ruptured, the shoulder and arm 
pressed down into the pelvis, and the uterus contracted round the 
body of the child. The uterus being firmly and spasmodically con- 
tracted, the attempt to introduce the hand often only makes matters 
worse, by inducing more frequent and stronger pains. Even if the 
hand and arm be successfully passed, much difficulty is often ex- 
perienced in causing the body of the child to rotate ; for we have no 
longer the fluid medium present in which it floated and moved with 



TURNING. 457 

ease, and the arm of the operator may be so cramped and pained, 
by the pressure of the uterine walls, as to be rendered almost power- 
less. The risk of laceration is also greatly increased, and the care 
necessary to avoid so serious an accident adds much to the difficulty 
of the operation. 

Value of Anaesthesia in Relaxing the Uterus. — In these perplexing 
cases various expedients have been tried to cause relaxation of the 
spasmodically contracted uterine fibres, such as copious venesection 
in the erect attitude until fainting is induced, warm baths, tartar 
emetic, and similar depressing agents. None of these, however, are 
so useful as the free administration of chloroform, which has practi- 
cally superseded them all, and often answers most effectually when 
given to its full surgical extent. 

Mode of Procedure. — The hand must be introduced with the pre- 
cautions already described. If the arm be completely protruded 
into the vagina, we should pass the hand along it as a guide, and its 
palmar surface will at once indicate the position of the child's abdo- 
men. No advantage is gained by amputation, as is sometimes recom- 
mended. When the os is reached, the real difficulties of the operation 
commence, and, if the shoulder be firmly pressed down into the brim 
of the pelvis, it may not be easy to insinuate the hand past it. It is 
allowable to repress the presenting part a little, but with extreme 
caution, for fear of injuring the contracted uterine parietes. It is 
better to insinuate the hand past the obstruction, which can generally 
be done by patient and cautious endeavors. Having succeeded in 
passing the shoulder, the hand is to be pressed forward in the intervals, 
being kept perfectly flat and still on the body of the foetus when the 
pains come on. It is much safer to press on it than on the uterine 
walls, which might readily be lacerated by the projecting knuckles. 
When the hand has advanced sufficiently far, it will be better, for 
the reasons already mentioned, to seize and bring down one knee 
only. 

Management of Cases in which the Foot is brought down but the Foetus 
will not Revolve. — Even when the foot has been seized and brought 
through the os, it is by no means always easy to make the child 
! revolve on its axis, as the shoulder is often so firmly fixed in the 
pelvic brim as not to rise towards the fundus. Some assistance may 
be derived from pushing the head upwards from without, which, of 
course, would raise the shoulder along with it. If this should fail, 
we may effect our object by passing a noose of tape or wire ribbon 
round the limb, by which traction is made downwards and back- 
wards; at the same time, the other hand is passed into the vagina to 
displace the shoulder and push it out of the brim. It is evident that 
this cannot be done as long as the limb is held by the left hand, as 
there is no room for both hands to pass into the vagina at the same 
time. By this manoeuvre version may be often completed, when the 
foetus cannot be turned in the ordinary way. Various instruments 
have been invented, both for passing a lac round the child's limb, and 
for repressing the shoulder, but none of them can compete, either in 
facility of use or safety, with the hand of the accoucheur. 



458 OBSTETRIC OPERATIONS. 

Should all attempts at version fail, no resource is left but the 
mutilation of the child, either by evisceration or decapitation. This 
extreme measure is, fortunately, seldom necessary, as with due care 
version may generally be effected, even under the most unfavorable 
circumstances. 



CHAPTEE III. 

THE FORCEPS. 



Of all obstetric operations the most important, because the most 
truly conservative both to the mother and child, is the application 
of the forceps. In modern midwifery the use of the instrument is 
much extended, and it is now applied by some of our most expe- 
rienced accoucheurs with a frequency which older practitioners would 
have strongly reprobated. That the injudicious and unskilful use of 
the forceps is capable of doing much harm, no one will for a moment 
deny. This, however, is not a reason for rejecting the recommenda- 
tion of those who advise a more frequent resort to the operation, but 
rather for urging on the practitioner the necessity of carefully study- 
ing the manner of performing it, and of making himself familiar with 
the cases in which it is easy or the reverse. Nothing but practice — 
at first on the dummy, and afterwards in actual cases — can impart 
the operative dexterity which it should be the aim of every obstetri- 
cian to acquire, and without which there can be no assurance of his 
doing his duty to his patient efficiently. 

Description of the Instrument. — The forceps may best be described 
as a pair of artificial hands, by which the foetal head may be grasped 
and drawn through the maternal passages by a vis a fronte, when 
the vis a tergo is deficient. This description will impress on the mind 
the important action of the instrument as a tractor, to which all its 
other powers are subservient. The forceps consists of two separate 
blades of a curved form, adapted to fit the child's head ; a lock by 
which the blades are united after introduction ; and handles which 
are grasped by the operator, and by means of which traction is made. 
It would be a wearisome and unsatisfactory task to dwell on all the 
modifications of the instrument which have been made, which are so 
numerous as to make it almost appear as if no one could practise 
midwifery with the least pretension to eminence, unless he has 
attached his name to a new variety of forceps. 

The Short Forceps. — The original instrument, invented by the 
Cliamberlens, may be looked upon as the type of the short straight 
forceps, which has been more employed than any other, and which, 
perhaps, finds its best representative in the short forceps of Denman 



THE FORCEPS 



459 



Fig. 150. 



(Fig. 150). Indeed the only essential difference between the two is 

the lock of the latter, originally invented by Smellie, which is so 

excellent that it has been adopted in all British forceps; and which, 

for facility of juncture, is much superior to either the French pivot, 

or the German lock, while for firmness 

it is, for all practical purposes, as good as 

either. In this instrument the blades 

are 7, the handles -if inches in length; 

the extremities of the blades are exactly 

1 inch apart, and the space between 

them, at their widest part, is 2| inches. 

The blades measure If inches at their 

greatest breadth, and spring with a 

regular sweep directly from the lock, 

there being no shank. The blades are 

formed of the best and most highly 

tempered steel, to resist the strain to 

which they are occasionally subjected, 

and they are smooth and rounded on 

their inner surface, to obviate the risk 

of injury to the scalp of the child. 

Advantages claimed for this Form of 
Instrument. — The special advantage 
claimed for this form of instrument is, 
that, the two halves being precisely 
similar, no care or forethought is re- 
quired on the part of the practitioner 
as to which blade should be introduced 
uppermost — an advantage of no great 
value, since no one should undertake a 
case of forceps delivery who has not 
sufficient knowledge of the operation, and presence of mind enough, 
to obviate any risk from the introduction of the wrong blade first. 
On account of its shortness, and the want of the second or pelvic 
curve, it is only adapted for cases in which the head is low clown in 
the pelvis, or actually resting on the perineum. 

The Pelvic Curve, its Advantages. — The question of the second or 
pelvic curve is one on which there is much difference of opinion. 1 
The forceps we are now considering, and the many modifications 
formed on the same plan, is constructed solely with reference to its 
grasp on the child's head, and without regard to the axes of the 
maternal passages. Consequently were Ave to introduce it when the 
head was at the upper part of the pelvis, we could not fail to expose 
the soft parts to the risk of contusion, and (in consequence of the 
necessity of drawing more directly backwards) unduly stretch and 
even lacerate the perineum. Hence it is now admitted by obstetri- 

[ : The credit of devising the pelvic curve is now given to Dr. Benjamin Pugh, of 
Chelmsford, Essex, England, 1736. Levret, in 1747, and Smellie, in 1751, both 
used it. They are thought to have acted independently in the invention. — Ed.} 




Denman's Short Forceps. 



460 



OBSTETRIC OPERATIONS, 



Fig. 151. 



cians, with few exceptions, that the second curve is essential before 
the complete descent of the head, although it is not absolutely so 
after this has taken place. The only circumstances under which a 
straight blade can possess any superiority are in certain cases of 
occipito-posterior position, in which it is found necessary to rotate 
the head round a large extent of the pelvis, when the circular sweep 
of a strongly-curved instrument might prove injurious. Such cases, 
however, are of rare occurrence, and need in no way influence the 
general employment of the pelvic curve. 

Zeigler's Forceps. — The short forceps, usually employed in Scot- 
land, is the invention of the late Zeigler (Fig. 151), 1 and is useful 
from the facility with which the blades may be 
introduced in accurate apposition to each other, a 
point which in practice is of no little value. In 
general size and appearance it closely resembles 
Denman's forceps, but the fenestrum of the lower 
blade is continued down to the handle. In intro- 
ducing, the lower blade is slipped over the handle 
of the other blade already in situ, and thus it is 
guided with great certainty into a proper position, 
locking itself as it passes on. This instrument has 
the disadvantage of not having the second curve, 
but the facility of introduction has rendered it a 
great favorite with many who have been in the 
habit of employing it. 

The Long Forceps. — For cases in which the head 
is not on the perineum, or at least not quite low in 
the pelvis, a longer instrument is essential. To 
meet this indication Smellie invented the long 
forceps, which, like the shorter instrument, has 
been very variously modified. The most perfect instrument of the 
kind employed in this country is that known as Simpson's forceps 
(Fig. 152), which combines many excellent points selected from the 
forceps of various obstetricians, as well as some original additions, 
and which, as a whole, has never been surpassed. The curved portions 
of the blades are 6J inches long, the fenestrum measuring \\ at its 
widest part. The extremities of the blades are 1 inch asunder when 
the handles are closed, and 3 inches at their widest part. The object 
of this somewhat unusual width is to lessen the compressing power 
of the instrument, without in any way interfering with, its action as 
a tractor. The pelvic curve is less than in most long forceps, so as 
to admit of the rotation of the head when necessary, without the risk 
of injuring the maternal structures. Between the curve of the blade 
and the lock is a straight portion or shank, measuring 2f inches, 
which, before joining the handle, is bent at right angles into a knee. 
This shank is a useful addition to all forceps, and is essential in the 
long forceps to insure the junction of the blades beyond the parts of 
the mother, which might otherwise be caught in the lock and injured. 




Zeigler's Forceps. 



[' It Las been made here, but is not regarded with any favor. — En.] 



THE FORCEPS. 



461 



The knees serve the purpose of preventing the blades from slipping 
from each other after they have been united. They also admit of 
one finger being introduced above the lock, and used as an aid in 
traction ; a provision which is made in some other varieties of long- 
forceps by a semicircular bend in 

each shank. The handles which Fig. 152. 

in most British forceps are too 
small and smooth to afford a firm 
grasp, are serrated at the edge, and 
flattened from before backwards, 
so as to fit the closed fist more 
accurately. At their extremities, 
near the lock, there are a pair of 
projecting rests, over which the 
fore and middle fingers may be 
passed in traction, and which 
greatly increase our power over 
the instrument. Although this, 
and other varieties of the long 
forceps, are specially constructed 
for application when the head is 
high in the pelvis, it answers quite 
as well as the short forceps — in- 
deed, in most respects better — ■ 
when the head has descended low 
down. It is a decided advantage 
for the practitioner to habituate 
himself to the use of one instru- 
ment, with the application and 
power of which he becomes 
thoroughly familiar. It is a mere 
waste of space and money for him Simpson's Forceps. 

to incumber himself with a num- 
ber of instruments of various shapes and sizes, and he may be sure 
that a good pair of long forceps, such as Simpson's, will be suitable 
for every emergency, and in any position of the head. 

Disadvantages of a Weak Instrument. — The chief argument against 
the use of such an instrument in simple cases is its great power. 
This, however, is entirely based on a misconception. The existence 
of power does not involve its use, and the stronger instrument can 
be employed with quite as much delicacy and gentleness as the 
weaker. The remarks of Dr. Hodge 1 on this point are extremely 
apposite, and are well worthy of quotation. He says, " Certainly no 
man ought to apply the forceps who has not sufficient discretion, to 
use no more force than is absolutely requisite for safe delivery ; if, 
therefore, there is more power at command, he is not obliged to use it; 
while, on the contrary, if much power be demanded, he can, within 
the bounds of prudence, exercise it by the long forceps, but with the 



e 



System of Obstetrics, p. 242. 



462 



OBSTETRIC OPERATIONS. 



Fig. 153. 



short forceps his efforts might be unavailing; moreover, in cases of 
difficulty, the short forceps being used, the practitioner would be 
forced to make great muscular efforts ; while with the long forceps, 
owing to the great leverage, such effort will be comparatively trifling, 
and, of course the whole force demanded can be much more deli- 
cately, and at the same time efficiently, applied, and with more safety 
to the tissues of the child and its parent." 

Continental Forceps. — The forceps usually employed on the Con- 
tinent, and in America, differ considerably, both in appearance and 
construction, from those in use in this country. As a rule it is a 
larger and more powerful instrument, joined by a pivot or button 
joint, and it always possesses the second or pelvic curve. Of late 
years Simpson's forceps has been much employed in some parts 

of Germany. The chief objection to 
the Continental instruments is their 
cumbrousness. This is chiefly in the 
handles, which in many of them are 
forged in a piece with the blades, the 
part introduced within the maternal 
structures not being materially differ- 
ent from the corresponding part of the 
English instrument. 

The forceps invented by Professor 
Tarnier (Fig, 153) have recently at- 
tracted considerable attention. In this 
instrument traction is not made on the 
handles by which the blades are intro- 
duced, as in ordinary forceps, but on a 
supplementary handle (a) subsequently 
attached to the blades near the lower 
opening of their fenestras (b). The 
object claimed for this arrangement is 
that less force is required in traction, 
which can always be made in the 
proper axis of the pelvis ; that the blades are not likely to slip ; and 
that rotation of the head is not interfered with. The instrument, 
however, is much more complex than that usually employed in this 
country, and does not seem to possess sufficient advantages to coun- 
terbalance this defect. [Professor Tarnier has adopted, in this in- 
strument, the blades of Davis. It has been much simplified recently, 
by Dr. Kichard A. Cleemann, of Philadelphia, by taking away the 
long curve of the handles, dispensing with the tongue, and bending 
forward the shanks. — Ed.] 

Action of the Instrument. — The forceps is generally said to act in 
three different ways : — 
1st. As a tractor. 
2d. As a lever. 
3d. As a compressor. 

The Chief Use of the Forceps as a Tractor. — It is more especially as 
a tractor that the instrument is of value, and it is used with the great- 




Tarnier's Forcep 



THE FORCEPS. 463 

est advantage when it is employed merely to supplement the action 
of the uterus, which is insufficient of itself to effect delivery, or when, 
from some complication, it is necessary to complete labor with greater 
rapidity than can be accomplished by the unaided powers of nature. 
In most cases traction alone is sufficient ; but, in order that it may 
act satisfactorily, and that the instrument may not slip, a proper con- 
struction of the forceps, and a sufficient curvature of the blades, are 
essential. The want of these is the radical fault of many of the 
short, straight instruments in common use, which have a tendency to 
slip during our efforts at extraction. 

As a Lever. — The forceps acts also as a lever, but this action has 
been greatly exaggerated. It is generally described as a lever of the 
first class, the power being at the handles, the fulcrum at the lock, 
and the weight at the extremities. There may possibly be some 
leverage power of this kind when the instrument is first introduced, 
and the handles held so loosely that one blade is able to work on the 
other. But, as ordinarily used, the handles are held with a suffi- 
ciently firm grasp to prevent this movement, and then the two blades 
practically form a single instrument. 

Galabin, who has studied this subject in detail, points out 1 that : 
"1. The lever is formed by both blades of the forceps and the foetal 
head united in one immovable mass. As soon as the blades begin 
to slip over the head, the lever is decomposed, and the swaying move- 
ment ceases to have any mechanical advantage. 2. The power is 
applied to the handles in a slanting direction. The resistance or 
weight does not act at a point either between the former and the 
fulcrum, or beyond the fulcrum, but at a point in a plane nearly at 
right angles to the line joining these two points ; and its direction is 
a line perpendicular to that plane of the pelvis in which the greatest 
section of the head is engaged, that is to say, in the case of straight 
forceps, nearly parallel to the handles. The lever formed does not, 
therefore, strictly speaking, belong to any one of the three orders 
into which levers are commonly divided. 3. The fulcrum is fixed 
partly by friction, partly by the combination of traction with oscil- 
latory movement — in other words, by the power being directed in 
great measure downwards, and only slightly to one side." 

He further shows that the pendulum motion of the forceps is super- 
fluous in all ordinary forceps operations, in which traction alone is 
amply sufficient for delivery ; but that when the head is impacted, 
and great force is required for its extraction, a mechanical advantage 
may be gained from having recourse to an oscillatory movement, 
which should, however, be very limited, and only continued if found 
to effect distinct advance of the head. 

As a Compressor. — Eegarding the compressive power of the instru- 
ment there has been much difference of opinion. There is no doubt 
that the forceps, especially some of the foreign instruments in which 
the points nearly approach each other, is capable of exerting con- 

1 Galabin, "Action of Midwifery Forceps as a Lever," Obstetrical Journal, 
November, 1876. 



464 OBSTETRIC OPERATIONS. 

siderable compression on the head. It is, however, extremely prob- 
lematical if this action be of real value. It is to be borne in mind 
that in cases of protracted labor the head has been already moulded 
and compressed, and the bones have been made to overlap each other 
to their utmost extent, by the sides of the pelvis ; we can scarcely, 
therefore, expect to diminish the head much more by the forceps, 
without employing an amount of force that will seriously endanger 
the life of the child. It is in cases of disproportion between the 
head and the pelvis, depending on slight antero-posterior contraction 
of the pelvic brim, that diminution of the child's head by compres- 
sion would be most useful. Then, however, the pressure of the 
forceps is exerted on that portion of the head which lies in the most 
roomy diameter of the pelvis, where there is no want of space. If 
this pressure do not increase the opposite diameter, which is in appo- 
sition to the narrower portion of the pelvis, it can at least do nothing 
towards lessening it ; and diminution of any other part of the child's 
head is not required. 

Dynamical Action of the Forceps. — The mere introduction of the 
forceps sometimes excites increased uterine action, through the reflex 
irritation induced by the presence of a foreign body in the vagina. 
This has been called the dynamical action of the forceps ; but it can- 
not be looked upon in any other light than that of an occasional 
accidental result. 

The circumstances indicating the use of the forceps have been 
separately considered elsewhere, and to recapitulate them here would 
only lead to needless repetition. I shall therefore now merely de- 
scribe the mode of using the instrument. 

Difference between the High and Loiv Operations. — Before doing so 
it is well to repeat what has already been said as to the difference 
between what may be termed the high and low forceps operations. 
The application of the instrument, when the head is low in the pelvis, 
is extremely simple ; and when there is no disproportion between the 
head and the pelvis, and some slight traction is alone required to 
supplement deficient expulsive power, the operation, in the hands of 
any ordinarily well-instructed practitioner, ought to be perfectly safe 
both to the mother and child. It is very different when the head is 
arrested at the brim, or high in the pelvis. Then the application of 
the forceps is an operation requiring much dexterity for its proper 
performance, and must never be undertaken without anxious con- 
sideration. It is because these two classes of operations have been 
confused that the use of the instrument is regarded by many with 
such unreasonable dread. 

Preliminary Considerations. — Before attempting to introduce the 
forceps, there are several points to which attention should be di- 
rected: — 

1st. The membranes must, of course, be ruptured. 

2dly. For the safe and easy application of the instrument, it is 
also advisable that the os should be fully dilated, and the cervix re- 
tracted over the head. Still, these two points cannot be regarded, as 
many have laid down, as being sine qua non. Indeed we are often 



THE FORCEPS. 465 

compelled to use the instrument when, although the os is fully dilated, 
the rim of the cervix can be felt at some point of the contour of the 
head, especially in cases in which the anterior lip is jammed between 
the head and the pubis. Provided due care be taken to guard the 
cervical rim with the fingers of one hand, as the instrument is 
slipped past it, there need be no fear of injury from this cause. If 
the os be not fully dilated, but is sufficiently open to admit of the 
passage of the forceps, the operation, under urgent circumstances, 
may be quite justifiable, but it must necessarily be a somewhat 
anxious one. 

3dly. The position of the head should be accurately ascertained 
by means of the sutures and fontanelles. Unless this be done, the 
operation will always be hap-hazard and unsatisfactory, as the prac- 
titioner can never be in possession of accurate knowledge of the pro- 
gress of the case. It maybe that the occiput is directed backwards; 
and, although that does not contra-indicate the application of the 
forceps, it involves special precautions being taken. 

4thly. The bladder and bowels should be emptied. 

Question of Administering Anaesthetics. — Before proceeding to ope- 
rate, the question of anaesthesia will arise. In any case likely to be 
difficult it is of the greatest assistance to have the patient completely 
under the influence of an anaesthetic to. the surgical degree, so as to 
have her as still as possible; but, whenever this is deemed necessary, 
another practitioner should undertake the responsibility of the admin- 
istration. In simple cases I believe it is better to dispense with anaes- 
thetics altogether, partly because they are apt to stop what pains 
there are, which is in itself a disadvantage, but chiefly because, under 
partial anaesthesia, the patient loses her self-control, is restless, and 
twists herself into awkward positions, which give rise to the utmost 
difficulty and inconvenience in the use of the instrument. Moreover, 
if no anaesthetic be given, the patient can assist the operator by 
placing herself in the most convenient attitude. 

Description of the Operation. — In describing the method of apply- 
ing the forceps, I shall assume that we have to do with the simpler 
variety of the operation, when the head is low in the pelvis. Sub- 
sequently I shall point out the peculiarities of the high operation. 

Position of the Patient. — As to the position of the patient, I believe 
there can be no doubt of the superiority of that which is usually 
adopted in this country. On the Continent and in America the for- 
ceps is always employed with the patient lying on her back, a posi- 
tion involving much needless exposure of the person, and requiring 
more assistance from others. In certain cases of unusual difficulty 
the position on the back is of unquestionable utility, but we may, at 
least, commence the operation in the usual way, and subsequently 
turn the patient on her back if desirable. 

Importance of a Suitable Position. — Much of the facility with which 
the blades are introduced depends on the patient's being properly 
placed. Hence, although it gives rise to a little more trouble at first, 
I believe that it is always best to pay particular attention to this 
point, whether the high or low forceps operation be about to be per- 



466 OBSTETRIC OPERATIONS. 

formed. The patient should be brought quite to the side of the bed, 
with her nates parallel to, and projecting somewhat over its edge. 
The body should lie almost directly across the bed, and nearly at 
right angles to the hips, with the knees raised towards the abdomen 

Fig. 154. 




Position of Patient for Forceps Delivery and Mode of Introducing Lower Blade. 

(Fig. 154). In this way there is no risk of the handle of the upper 
blade, when depressed in introduction, coming in contact with the 
bed. 

The blades should be warmed in tepid water, lubricated with cold 
cream or carbolic oil, and placed ready to hand. 

These preliminaries having been attended to, we proceed to the in- 
troduction of the blades, sitting by the side of the bed, opposite the 
nates of the patient. 

Direction in which the Blades are to be Introduced. — The important 
question now arises, in what direction are the blades to be passed? 
The almost universal rule in our standard works is, that they mast 
be passed as nearly as possible over the child's ears, without any re- 
ference to the pelvic diameters. Hence, if the head have not made 
its turn, but is lying in one oblique diameter, the blades would re- 
quire to be passed in the opposite oblique diameter ; in short, the 
position of the forceps, as regards the pelvis, must vary according 
to the position of the head. Some have even laid down the rule, 
that the forceps is contra-indicated unless an ear can be felt; a rule 
that would very seriously limit its application, as in many cases in 
which it is urgently required it is a matter of great difficulty, and 
even impossibility, to feel the ear at all. [This is not the practice in 
this country with those who use the forceps of Hodge, Wallace, or 
Davis, which are designed to be applied over the parietal protuber- 
ances whenever practicable. — Ed.] It is admitted that in the high 



THE FORCEPS. 467 

forceps operation the blades must be introduced in the transverse 
diameter of the pelvis, without relation to the position of the head. 
On the Continent it is generally recommended that this rule should 
be applied to all cases of forceps delivery alike, whether the head be 
high or low, and I have now for many years adopted this plan, and 
passed the blades in all cases, whatever be the position of the head, 
in the transverse diameter of the pelvis, without any attempt to pass 
them over the bi-parietal diameter of the child's head. Dr. Barnes 
points out with great force that, do what we will, and attempt as we 
may, to pass the blades in relation to the child's head, they find their 
way to the sides of the pelvis, and that the marks of the fenestra on 
the head always show that it has been grasped by the brow and side 
of the occiput. [That is because the variety of forceps used does 
not conform to the contour of the head. — -Ed.] Of the perfect cor- 
rectness of this observation I have no doubt ; hence it is a needless 
element of complexity to endeavor to vary the position of the blades 
in each case, and one which only confuses the inexperienced practi- 
tioner, and renders more difficult an operation which should be sim- 
plified as much as possible. While, therefore, it is of importance 
that the precise position of the head should be ascertained in order 
that we may have an intelligent notion of its progress, I do not 
think that it is essential as a guide to the introduction of the 
forceps. 

Method of Introducing the Lower Blade. — As a rule the lower blade, 
lightly grasped between the tips of the index and middle fingers and 
thumb, should be introduced first. Poised in this way, we have per- 
fect command over it, and can appreciate in a moment any obstacle 
to its passage. Two or more fingers of the left hand are introduced 
into the vagina, and by the side of the head, as a guide ; the greatest 
care must be taken, if the cervix be within reach, that they are 
passed within it, so as to avoid the possibility of injury. 

Necessity of Gentleness in Passing the Instrument. — The handle of 
the instrument has to be elevated, and its point slid gently along the 
palmar surface of the guiding fingers, until it touches the head (Fig. 
154). At first the blade should be inserted in the axis of the outlet, 
but, as it progresses, the handle must be depressed and carried back- 
wards. As it is pushed onwards it is made to progress by a slight 
side-to-side motion, and it is of the utmost importance to bear in 
mind that the greatest gentleness must always be used. If any ob- 
struction be felt, we are bound to withdraw the instrument, partially 
or entirely, and attempt to manoeuvre, not force, the point past it. 
As the blade is guided on in this way, it is made to pass over the con- 
vexity of the head, the point being always kept lightly in contact 
with it, until it finally gains its proper position. When fully inserted 
the handle is drawn back towards the perineum, and given in charge 
to an assistant. The insertion must be carried on only in the inter- 
vals between the pains, and desisted from during their occurrence ; 
otherwise there would be a serious risk of injuring the soft parts of 
the mother. 



468 



OBSTETRIC OPERATIONS 



Introduction of the Upper Blade. — The second blade is passed di- 
rectly opposite to the first, and is generally somewhat more difficult 
to introduce, in consequence of the space occupied by the latter. It 
is passed along two fingers directly opposite the first blade, and with 
exactly the same precautions as to direction and introduction, except 
that at first its handle has to be depressed instead of elevated (Fig. 
155). 

Fig. 155. 




Introduction of the Upper Blade. 



Locking of the Handles. — The handle which was in charge of the 
assistant is now laid hold of by the operator, and the two handles 
are drawn together. If the blades have been properly introduced, 
there should be no difficulty in locking ; but, should we be unable to 
join them easily, we must withdraw one or other, either partially or 
entirely, and reintroduce it with the same precautions as before. We 
must also assure ourselves that no hairs, nor any of the maternal 
structures are caught in the lock. 

Method of Traction. — When once the blades are locked we may 
commence our efforts at traction. To do this we lay hold of the 
handles with the right hand, using only sufficient compression to 
give a firm grasp of the head, and to keep the blades from slipping. 
The left hand may be advantageously used in assisting and support- 
ing the right during our efforts at extraction, and, at a late stage of 
the operation, may be employed in relaxing the perineum when 
stretched by the head of the child. Traction must always be made 
in reference to the pelvic axes; being at first backwards towards the 
perineum (Fig. 156), in the direction of the axis of the brim, and as 
the head descends and the vertex protrudes through the vulva, it 
must be changed to that of the outlet. We must extract only during 
the pains; and, if these should be absent, we must imitate them by 



THE FORCEPS. 



469 



acting at intervals. This is a point which deserves special attention, 
for there is no more common error than undne hurry in delivery. 
The only valid objection I know of against a more frequent resort 
to the forceps in lingering labors is, that the sudden emptying of the 



Fig. 156. 




Forceps in Position. Traction in the Axis of the Brim, downwards and backwards. 



uterus, in the absence of pains, may predispose to hemorrhage; and 
it cannot be denied that it is one of some weight. However, if due 
care be taken to operate slowly, and to allow several minutes to 
elapse between each tractive effort, while, at the same time, uterine 
contractions be stimulated by pressure and support, this need not be 
considered a contra-indication. Besides direct traction we may im- 
part to the instrument a gentle waving motion from handle to handle, 
which brings into operation its power as a lever; but this must not 
be done to any great extent, and must always be subservient to direct 
traction. 

Descent of the Head. — Proceeding thus in a slow and cautious 
manner, carefully regulating the force employed according to the 
exigencies of the case, we shall perceive that the head begins to 
descend ; and its progress should be determined, from time to time, 
by the fingers of the unemployed hand. 

The Rotation from the Oblique Diameter. — When the head lies in 
the oblique diameter, as it descends, in consequence of its perfect 
adaptation to the pelvic cavity, it will turn into the antero-posterior 
diameter without any effort on the part of the operator, provided 
only that the traction be sufficiently slow and gradual. As the head 
is about to emerge, it is necessary to raise the handles towards the 
mother's abdomen. More than usual care is required to prevent 



470 



OBSTETRIC OPERATIONS. 



laceration of the perineum, which is always much stretched (Fig. 
157). If, as often happens, the pains have now increased, and the 
perineum be very thin and tense, it may even be desirable to remove 
the blades gently, and leave the case to be terminated by the natural 
powers ; but if due precautions are used this need not be necessary. 



Fig. 157. 




Last Stage of Extraction. The Handles of the Forceps turned upwards towards the Mother's 

Abdomen. 



The peculiarities of forceps delivery in occipito-posterior positions 
have already been discussed (p. 307), and need not be repeated. 

High Forceps Operations. — When the high forceps operation has 
been decided on, the passage of the blades will be found to be much 
more difficult from the height of the presenting part, the distance 
which they must pass, and, in some cases, from the mobility of the 
head interfering with their accurate adaptation. The general prin- 
ciples of introduction and of traction are, however, identical. If the 
operation be attempted before the head has entered the pelvic brim, 
it must be fixed, as much as possible, by abdominal pressure. In 
guiding the blades to the head special care must be taken to avoid 
any injury of the soft parts, especially if the cervix be not com- 
pletely out of reach. For this purpose it may even be advisable to 
introduce the entire left hand as a guide, so as to avoid any possi- 
bility of injuring the cervix, from not passing the instrument under 
its edge. 

Peculiar Method of Introducing the Blades. — Some authors advise 
that, in such cases, the blade should be introduced at first opposite 



THE FORCEPS. 471 

the sacrum, until the point approaches its promontory. It is then 
made to sweep round the pelvis, under the protecting fingers, till it 
reaches its proper position on the head. This plan is advocated by 
Eamsbotham, Hall Davis, and other eminent practical accoucheurs, 
and it is certainly of service in some cases of difficulty ; especially 
when, from any reason, it is not possible to draw the nates over the 
edge of the bed, when the necessary depression of the handle of the 

I upper blade is difficult to effect. It involves, however, a somewhat 
complicated manoeuvre, and it is seldom that the blades cannot be 

j readily introduced in the usual w T ay. 

Necessity of Care in Locking. — In locking the slightest approach 
to roughness must be carefully avoided, for the extremities of the 
blades are now within the cavity of the uterus, and serious injury 
might easily be inflicted. If difficulty be met with, rather than em- 
ploy any force, one of the blades should be withdrawn, and reintro- 

• duced in a more favorable direction. If the blades have shanks of 
sufficient length, there should be no risk of including the soft parts 
of the mother in the lock, which, in a badly constructed instrument, 
is an accident not unlikely to occur. 

Method of Traction. — After junction traction must at first be alto- 

I gether in the axis of the brim, and to effect this the handles must be 

1 pressed well backwards towards the perineum. As the head descends 
it will probably take the usual turn of itself, without effort on the 
part of the operator, and the direction of the tractive force may be 
gradually altered to that of the axis of the outlet. 

If the pains be strong and regular, and there be no indication for 
immediate delivery, we may remove the forceps after the head has 
descended upon the perineum, and leave the conclusion of the case 
to nature. This course may be especially advisable if the perineum 
and soft parts be ud usually rigid ; but generally it is better to termi- 
nate labor without removing the instrument. 

Possible Dangers of Forceps Delivery. — Before concluding this sub- 
ject, reference may be made to the possible dangers of the operation. 
I would here again insist on the importance of distinguishing be- 
tween the high and low forceps operations, which have been so unfor- 
tunately and unfairly confounded. Seasons have already been given 
for rejecting the statistics of the risks attending forceps delivery in 
the latter class of cases (p. 335). A formidable catalogue of dangers, 
both to the mother and child, might easily be gathered from our 
standard works on obstetrics. Among the former the principal are 
lacerations of the uterus, vagina, and perineum ; rupture of varicose 
veins, giving rise to thrombus ; pelvic abscess, from contusion of the 
soft parts; subsequent inflammation of the uterus or peritoneum; 
tearing asunder of the joints and symphyses; and even fracture of 
the pelvic bones. A careful analysis of these, such as has been so 
well made by Drs. Hicks and Philips, 1 proves beyond doubt that the 
application of the instrument is not so much concerned in their pro- 
duction, as the protraction of the labor, and the neglect of the practi- 

1 Obst. Trans., vol. xiii. 



472 OBSTETRIC OPERATIONS. 

tioner in not interfering sufficiently soon to prevent the occurrence 
of the evil consequences afterwards attributed to the operation itself. 
Many of these will be found to arise from the prolonged pressure on 
the soft parts within the pelvis, and the subsequent inflammation or 
sloughing. To these causes may be referred with propriety most 
cases of vesico- vaginal fistula (p. 427), peritonitis, and metritis fol- 
lowing instrumental labor. 

Lacerations and similar accidents may, however, result from an 
incautious use of the instrument. Slight lacerations of the mucous 
membrane of the vagina are probably far from uncommon. But if 
these cases were closely examined, it would be found that the fault 
lay not in the instrument, but in the hand that used it. Either the 
blades were introduced without due regard to the axes of the pelvis, 
or they were pushed forwards with force and violence, or an instru- 
ment was employed unsuitable to the case (such as a short straight 
forceps when the head was high in the pelvis), or undue haste and 
force in delivery were used. It would be manifestly unfair to lay 
the blame of such results upon the forceps, which, in the hands of a 
more judicious and experienced practitioner, would have effected the 
desired object with perfect safety. The instrument is doubtless 
unsafe in the hands of any one who does not understand its use, just 
as the scalpel or amputating knife would be in the hands of a rash 
and inexperienced surgeon. The lesson to be learnt seems to be 
clearly, not that the dangers should deter us from the use of the 
forceps, but that they should induce us to stud}?- more carefully the 
cases in which it is applicable, and the method of using it with 
safety. 

Possible Risks to the Child. — The dangers to the child are princi- 
pally, lacerations of the integuments of the scalp and forehead ; con- 
tusion of the face ; partial, but temporary, paralysis of the face from 
pressure of a blade on the facial nerve ; depression or fracture of the 
cranial bones ; injury to the brain from undue pressure of the blades. 
These evils are of rare occurrence, and when they do happen, gene- 
rally result from improper management of the operation — such as 
undue compression, the use of improper instruments, or excessive 
and ill- directed efforts at traction — and cannot, therefore, be con- 
sidered as in any way contra-indicating the use of the instrument. 
Many of the more common results, such as slight abrasions of the 
scalp, or paralysis of the face, are transitory in their nature and of 
no real consequence. 

[Although obstetrical forceps were first used in England, other 
countries in the march of improvement have made great changes, 
not only in the original forms, but in their manner of use ; and diffe- 
rent shapes, as well as different positions of the woman in application, 
have become in a measure almost national. With the exception of 
having adopted almost exclusively the French and German dorsal 
decubitus in making use of the instruments, we have become in a 
measure eclectic in the selection of the latter ; medical schools, accou- 
cheurs, and local obstetrical societies, influencing students and the 



THE FORCEPS. 473 

junior members of the profession, to adopt the French, German, 
English, or American styles, as the case may be, the forceps them- 
selves bearing the names of their several inventors, or compilers ; 
for some are a trne compilation, the blade, from one contriver ; fenes- 
tra! openings, another ; pelvic curve, a third ; width, a fourth ; shanks, 
a fifth; method of locking, a sixth; etc. etc. For this reason the 
late Prof. Hodge named his forceps the eclectic, although in some re- 
spects entirely original, particularly in the long superimposed shanks, 
a great improvement for operating at the superior strait, and avoid- 
ing the painful stretching of the posterior commissure. Dr. Hodge 
expended a great deal of thought and money in perfecting his forceps, 
and the various steps in the process were marked bj r a new form, 
until, from a heavy, clumsy instrument, he gradually evolved what 
was at one time regarded as a wonderful improvement upon the 
forceps of France and England, 

A contemporary of Prof. Hodge, the late Prof. David D. Davis, ot 
London, was equally anxious to perfect the instrument, and turned 
his attention especially to making the blades light, open, and to so 
fit the sides of the foetal head as to enable traction to be made with- 
out much pressure, or leaving any mark on the child's scalp. There 
is a principal of mechanics involved in his instrument, which he 
studied to perfect, by moulding the blades so as to obtain conside- 
rable coaptating surface, and thus by increase of friction avoid undue 
and dangerous pressure. The Davis blade soon began to effect 
changes in the form of American forceps, and by the addition ot 
long handles, and some alterations of shape, weight, and curve, be- 
came a leading feature in those bearing the names of AYilliam Harris, 
Prof. TVallace, of the Jefferson Medical College, Dr. Bethel, and 
Albert H. Smith, all of this city. The short Davis instrument was 
a great favorite of the late Prof. Meigs, and Dr. William Harris, both 
largely engaged in obstetrical practice, as well as teaching, and many 
a delicate woman, with wasting forces, was aided in her delivery at 
their hands, and surprised to find no mark on the baby's head, and 
that her own sufferings could be so gently and safely relieved. 

Although such was the estimation of the Davis blade, and still is 
in many parts our country, it does not appear to have retained its 

' popularity, or been adopted, as its mechanical perfection would lead 
one who appreciates it to suppose it would have been. In Great 

; Britain, the favorite forms now in use are but a very slight improve- 
ment upon the forceps of a hundred years ago, except in finish and 

, material, the open fenestra? and bevelled blades of Davis being de- 

'dined in favor of the looped fenestra? and flat-edged blades in use 
when he made his experiments and changes. This appears to have 

igrown out of a practice which has been largely adopted in Germany, 

i Great Britain, and many parts of the United States, in applying the 
forceps to the foetal head, the blades being introduced at the sides of 
die pelvis, without much reference to the position which the head 

'occupies. As compression is objected to, the blades are made long 
and widely separated (3 J to 3 J), and the handles short, so as not to 
allow of much leverage. As the blades do not fit the head, the 
31 



474 



OBSTETRIC OPERATION! 



mechanism of labor as' taught by Hodge has been much simplified, 
as it is not necessary to learn all the oblique fittings of the fenestras 
over the parietal protuberances or ears. Dr. Meigs used to tell the 
students that the forceps was the " child's instrument" and should be 
used as a tractor ; and it was, as a well applied mechanical tractor 
that he advocated the use of the Davis blades, against those of Sie- 
bold, Levret, Baudelocque, and Haighton, employed generally in our 
country forty years ago. His language is not very complimentary 
to what he denominates by distinction " the mother's instrument" the 
form being better adapted for saving the woman than the foetus. 
(" Obstetrics," p. 540.) 

At the present day we have two general varieties of forceps in 
use in the United States ; under each of which may be placed a vast 
number of special forms, which are simply changes upon one or the 
other general type, according to the fancy of the inventor. At the 
head of one type, may be placed the long forceps of Prof. Hodge, 
designed to be adapted to the sides of the child's head 
Fig. 158. in all possible cases : and of the other, those of Prof. 
Simpson, of Edinburgh, or their modification by Profs. 
Elliot and Bedford, of New York, intended to be used 
as tractors, and applied in reference to the sides of 
the mother's pelvis, rather than to those of the in- 
fant's head. 

Taking the long forceps of Levret and Baudelocque 
as improved and modified by Hodge ; with the blades 
of Prof. Davis as a substitute, and handles of less 
curve than those of Hodge; and we have the long 
forceps of Prof. Ellerslie Wallace, of the Jefferson 
College, the favorite instrument with, those who pur- 
chase forceps of the manufacturers in this city. Next 
in popularity are the instruments of Hodge, Davis, 
and Simpson, Elliot, Bedford, and a few others, in all 
about a dozen forms that are kept in stock. The 
improvement of the late Prof. Elliot upon the instru- 
ment of Simpson, consists in narrowing and length- 
ening the shanks; widening somewhat the fenestra^; 
elongating the blades; giving greater security against 
slipping in the handles; and gauging the distance 
between the blades by a milled-head screw-stop in 
the end of the handles: the shanks and blades are an 
exact counterpart of the Miller forceps of England, 
which appeared about the same time, 1858. 

The Hodge forceps were based in their contrivance 
upon the following points: 1. The instrument should 
be shaped to the contour of the foetal head, and have 
sufficient play to allow of compression, where the 
pelvis is too narrow for the head to pass in its normal 
condition. 2. The blades should be so arranged in 
reference to the shanks and handles as to enable them to seize the 
head of the foetus in its bi-parietal diameter at the superior straight, 



THE FORCEPS. 



475 



and be drawn upon in the direction of the curve of the pelvic canal 
until the deliver}- is complete. 3. The long forceps ought to be 
competent to act either at the superior strait of the pelvis, in its 
cavity, or at its outlet, so as to avoid a multiplicity of instruments 
and their attendant expense. And 4. The instrument should not 
cut the scalp of the child if properly adjusted, or injure the soft 
parts of the mother. 

It would be folly to claim that all this could or has been accom- 
plished ; as there must necessarily be exceptional cases in all the points 
given ; hence the contrivance of the forceps of Tarnier and Cleemann 
for certain presentations above the superior strait; and the long and 
short convertible instruments of a few inventors. There are many 
cases of labor in the higher walks of life where, although there is 
no obstruction, still the women require manual or instrumental 
assistance, as the}- cannot deliver themselves for want of sufficient 
contractile muscular force. Such women require that the forceps 
used should be easily introduced; should act simply as tractors; 
control the movement of the foetal head by being well fitted to its 
shape, and leave no effect upon the scalp or vulva. Although these 
requisites mRj be filled by the Hodge instrument, it is this class of 
cases that has demanded a lighter and more roomy pair of forceps, 
such as that devised by Davis. 

As the teaching of the Jefferson Fig. 159. Fig. 160. 

Medical College under Dr. Meigs, 
favored as we have stated the for- 
ceps of Davis, so his successor in 
carrying out in a measure the 
same views, has combined the 
blades of the Davis pattern, with 
the long handles of Hodge, in con- 
triving the Wallace forceps, now 
so much in use by the large number 
of graduates of this school. As 
compared with the Hodge instru- 
ment, it is one inch shorter (15 
inches against 16); the blades are 
of the same length (6 inches) the 
fenestra are more open ; the shanks 
are only half the length, giving a 
much greater compressing power; 
and the handles are of the same 
measurement from pivot to hooks. 
Both have the Siebold lock, over 
which we believe the broad-topped 
button and notch to possess some 
advantages; and the Wallace is 
somewhat heavier than the Hodge 
which should weigh 17 ounces. 

The short Davis instrument 
made for Prof. Meigs under direc- 
tion Of the inventor Weighed 10J Wallace Forceps. 




476 



OBSTETKIC OPERATIONS 



ounces, and measured 12 inches in length; fenestra 5 inches long, 2 
inches wide; blades separated 2£ inches. Handles 4J inches to lock, 
which was of the Smellie or English pattern. A recently purchased 
pair in possession of the editor is 13 J inches long, with 5 inch handles, 
a button lock, 2 inch close set shanks, and 6J inch 
Fig. 161. blades. We believe the changes are decided im- 

provements, especially the lock and elongated 
handles. It has answered admirably in adynamic 
cases, requiring only a few pounds of tractile assist- 
ance. The Davis blades have been added to long 
handles, and the whole made of steel and marvel- 
lously light, at the special request of a few accouch- 
eurs, who wished them to aid in some cases of arrest 
at the perineum. 

The late Prof. George T. Elliot, of New York, 
who received much of his practical obstetrical train- 
ing in the Dublin Lying-in Hospital, imbibed the 
teachings of the English school, and became im- 
pressed with the value of the system as taught by 
Simpson ; after the principle of whose forceps, 
modelled somewhat after that of the late Prof. Gun- 
ning G. Bedford, of New York, he in 1858, presented 
to the medical profession the instrument that bears 
his name. The forceps of Prof. Bedford has a trac- 
tion ring on each side, where the Elliot has a corn a, 
has a button joint, instead of a Smellie, has no 
screw stop, and has diverging, instead of superim- 
posed shanks. These points have generally been 
considered as improvements, and hence the Elliot 
has taken precedence in large measure over the 
Bedford instrument in • New York sales, the two 
being the leading forceps in demand. The instru- 
Eiiiot Forceps. ment of White, of Buffalo, is perhaps next, and 
then Hodge's. But few of Prof. Wallace's forceps, 
the leading instrument in the Philadelphia trade, are ordered. The 
White is a long forceps, a compound of the Elliot blade, long super- 
imposed shanks of Plodge, Siebold lock, and short corrugated steel 
handles bowed out like dental forceps, and ending in thin blunt hooks. 
The Sawyer and Simpson short forceps are about equally in de- 
mand in New York. The former is unknown to the trade here ; and 
but comparatively few of the Simpson are sold, although the system 
of their application has several advocates in Philadelphia. 

We have here a representation of one of the lightest of all the 
varieties of the short forceps, weighing but 5 ounces, and measuring 
9 1 inches in length ; the handle being 3 inches, shank 1}, and chord 
of blade-curve 5 J. The blades are 1 J inches wide, with oval fenes- 
tra J inch wide, and are separated 2f inches at their widest part, 
and f inch at the tips. 

This instrument was invented about two years and a half ago, by 
Prof. Edw. Warren Sawyer, of Push Medical College, Chicago, and 



THE FORCEPS. 



477 



Fig. 162. 



has been highly commended by Prof. Byford and others. The for- 
ceps have the blades of Davis, superimposed shanks of Hodge, and 
lock of Smellie, with hard-rubber plates 
moulded hot upon the handles. The several 
parts have been somewhat modified ; the ob- 
ject being to secure a tractor for cases of defi- 
cient expulsive force, where the foetal head is 
low in the pelvis. 

Professor Sawyer says : " In the labors to 
which my forceps are applicable it is not ne- 
cessary for the operator's body to be in line 
with the pelvic axis. My mode of procedure 
is the following : The woman is placed upon 
her back and drawn to the edge of the bed, 
the outside leg is now flexed ; beneath, this 
flexed extremity and the bed covering, I apply 
the forceps — often using but one hand in the 
operation. When the instrument is locked, I 
grasp the handle in such a manner that the 
palm of the hand looks upward ; one hook 
then rests naturally upon the extensor surface 
of the first phalanx of the index finger, while 
the other hook rests upon a corresponding 
part of the thumb. When thus adjusted, I 
lift the head from the pelvic outlet, at the same 
time invoking the pendulum movement if de- 
sired. At this moment the advantage of the 
hooked handle is very apparent to the opera- 
tor." ..." All practitioners must have often felt, during the 
last moments of labor, when the uterus and the mother seemed 
fatigued, the need of a little help to the expulsive powers. The or- 
dinary instruments are too formidable to be used at the last moment, 
and it is then that this little forceps is useful." 

We have given the names and characters of the various forceps 
most in use in New York and Philadelphia ; and by the large num- 
ber of graduates of their respective schools, as shown by their pre- 
ferences in making purchases of the leading instrument makers of 
the two cities. The mechanism of instrumental delivery is much 
simplified by applying the forceps to whatever parts of the foetal 
head may be opposite the sides of the pelvis ; but it is very ques- 
tionable whether it is the scientific method, or the safer for the child. 
With one blade over the side of the occiput, and the other over that 
of the forehead, which is the manner of seizure in oblique positions 
of the vertex, we certainly have not a very secure hold, and run 
some risk of injury to the foetus. The advocates of this system 
claim that they use no compression, only a simple traction ; which, 
may be true in one sense, but amounts to the same in effect, else how 
could Dr. Elliot, by traction with great force, straighten out one of 
the blades of his Simpson forceps, as related in the " N. Y. Journ. of 
Med." for September, 1858, page 161, in the paper which he pre- 




Sawyer Forceps. 



478 



OBSTETRIC OPERATIONS 



sented, describing his new forceps and a number of cases in which, 
he had tested them. It makes but little difference whether we com- 
press the head before we begin to pull, or pull so as to wedge the 
head between the blades and thus compress it, except as to the differ- 
ence of fit in the two instances; the adjusted and even pressure, 
being the less likely to injure the foetus. We have always believed 
that the forceps should fit the head, and that the student should be 
taught how to accomplish it correctly in the various positions of the 
foetus. If the student has a mechanical turn of mind, a delicate 
sense of touch, and a clear head, he will soon learn : if he is not a 
mechanic, he will be forced to adopt a more simple method of de- 
livery. In a large city, there are but few first class obstetrical 
manipulators as a general rule, and they are usually well known as 

Fig. 163. 




Application of the Forceps at the Inferior Strait. 



such, for the reason that but few have all the requisites to enable 
them to achieve notoriety ; and yet there are hundreds who can de- 
liver a woman with forceps moderately well. To one, the mechan- 
ism of Hodge is a simple matter, and soon mastered; to another, it is 



THE FORCEPS. 479 

a useless complication, and he prefers the more simple system. 
Hence the great differences between obstetricians, as to the best in- 
strument, and the best method of application. Some of the vast 
array of patterns have decided merit, and display much mechanical 
skill ; while others serve only to amuse the educated examiner. One 
obstetrician, like Elliot, uses a variety of forceps one after another in 
the same case, and palls with great force ; while another confines his 
work almost to one instrument, adjusts it easily, pulls moderately, 
and seldom fails. There are no doubt exceptions, but certainly the 
most delicate manipulators we have seen, believed in and practised 
the teachings of Hodge and Meigs. There may be cases where it 
might be well to practise the method of Simpson, as is done occa- 
sionally by some of our leading practitioners ; but we cannot see 
why his plan of delivery should be exclusively used on any mode of 
scientific reasoning. 

We present a series of plates in illustration of the American 
method of delivery with, the forceps ; the position, as will be seen, 
being that of France and Germany — on the back. When it is de- 
cided to use the forceps, in almost all cases in the United States, the 
patient is brought to the edge of the bed on her back, with her nates 
close to the edge, her feet on two chairs, and her knees widely sepa- 
rated, as in the plate above. The patient is covered with a sheet, or 
heavier covering if in winter, and there is no necessity of exposure, 
as the whole manipulation may be done by the sense of touch. The 
position is by far the most convenient for the obstetrician, and enables 
him much more easily to keep in his mind all the anatomical rela- 
tions of the foetus and pelvis, than when in the English decubitus. 
We study the anatomy, with the subject on the back, and the 
mechanism of labor in front of the pelvis, or mannikin, then why 
complicate matters by a change of position, which, to say the least, 
is a very awkward one, particularly in introducing the long forceps, 
setting them according to the instructions of Hodge, and carrying 
them forward between the thighs as the head emerges ? We have 
used the short forceps in an exhausted case, with the woman on her 
side, but found it much less convenient for the various movements, al- 
though we soon delivered the foetus. As to the question of exposure, 
there is less in appearance than in fact, in the English position, in 
many cases. If the patient and nurse are fastidious and careful 
during the use of the forceps, the accoucheur can manage without 
his eyes in a large proportion of cases; but the fault of exposure 
lies more frequently in the temporary reckless indifference begotten 
of pain and suffering in the woman, than in any act of the accou- 
cheur, if inclined to spare the feelings of his patient as much as 
possible. 

The long forceps, with its pelvic curve, was specially designed for 
use at the superior strait of the pelvis, the curve of the blades, as in 
the Davis instrument modified by Wallace, being intended to cor- 
respond with the direction of the occipito- mental diameter of the 
foetal head. The long superimposed shanks of several varieties of 
the long forceps will here be found valuable, as the lock is not intro- 



480 



OBSTETRIC OPERATIONS. 



duced, or the posterior commissure of the vulva widely stretched. 
If the head is entirely above the strait, the line of the blades must 
be changed correspondingly, in order to apply them properly, and 
keep the line of traction within the coccyx; and even then, to draw 



Fig. 164. 




Application of the Forceps with the Head at the Superior Strait ; the left blade held in place by an 

Assistant. 



in the proper direction, the left hand must act at first in a backward 
direction from the lock; while the right brings the handles down- 
ward, forward, and then upward; both hands describing a curve, but 
that of the right being much the greater. The peculiar forceps of 
Tarnier, or of Cleemann, being designed to meet this form of exi- 
gency, may be brought into requisition. 

In latter years it has become much more common than formerly 
to introduce the forceps into the uterus, before it is fully dilated, in 



THE FORCEPS 



481 



consequence of the success claimed for the plan as carried out in the 
Dublin Lying-in Hospital. As this should never be done where the 
os is not readily dilatable, and requires much skill in execution, it is 
not safe to recommend its general adoption in cases of delay in pri- 
vate practice. 

The forceps should not be introduced with any force, but the left 
blade should be slid in gently, and with a spiral motion, and then 
the right; care being taken that they should also lock without force, 
which they will do if properly adjusted. Traction is to be exerted 
slowly, and during a pain, the whole movement being made to cor- 
respond with the natural as closely as possible. 

Fig. 165. 




Direction of the Forceps as the Head is being Delivered. 



As the foetal head comes under the arch of the pubes, the handles 
of the forceps must rise more and more from the bed, until at last 
they are over the abdomen, as the head emerges from the perineum. 
This last movement of instrumental delivery should be a very slow 
one, for fear of rupture. It has been proposed to remove the blades 
before delivery is complete ; but there is no occasion for this, if the 
forceps are applied to the sides of the head over the parietal protru- 
berances ; as where these protrude, and the blades are flat and thin, 
there is very little additional space required. With such instruments 
as the old Levret, Baudelocque, and Rohrer forceps, with looped or 



482 OBSTETRIC OPERATIONS. 

kite-shaped fenestra, and thick edges, this was a much more impera- 
tive direction, than with the better instruments of the present day. 
With a Sawyer forceps the perineum ought to be safer, and under 
better control than without. When the perineum is thought to be 
in danger, the process of distension should be retarded through two 
or three pains, or even more if required, instead of drawing the head 
through at once. 

After the head is delivered, if the cord is not around the neck, 
and, therefore, in danger from pressure, the body should be allowed 
to remain until the uterus has well contracted upon it, for fear of 
hemorrhage after delivery from uterine inertia. — Ed.] 



CHAPTEE IY. 

THE VECTIS — THE FILLET. 

In connection with the subject of instrumental delivery it is essen- 
tial to say something of the use of the vectis, on account of the value 
which was formerly ascribed to it, which was at one time so great in 
this country that it became the favorite instrument in the metropolis ; 
Denman saying of it that even those who employed the forceps were 
" very willing to admit the equal, if not superior, utility and conve- 
nience of the vectis." Even at the present day, there are practi- 
tioners of no small experience who believe it to be of occasional 
great utility, and use it in preference to the forceps in cases in which 
slight assistance only is required. In spite, however, of occasional 
attempts to recommend its use, the instrument has fallen into dis- 
favor, and may be said to be practically obsolete. 

Nature of the Instrument. — The vectis, in its most approved form, 
consists of a single blade, not unlike that of a short straight forceps, 
attached to a wooden handle. A variety of modifications exist in its 
shape and size. The handle has been occasionally manufactured, for 
the convenience of carriage, with a hinge close to the commencement 
of the blade (Fig. 166), or with a screw at the point where the handle 
and blade join. The power of the instrument, and the facility of 
introduction, depend very much on the amount of curvature of the 
blade. If this be decided, a firmer hold of the head is taken and 
greater tractive force is obtained, but the difficulty of introduction is 
increased. 

The vectis is used either as a lever or a tractor. When employed in 
the former way, the fulcrum is intended to be the hand of the ope- 
rator; but the risk of using the maternal structures as a point oVappui, 
and the inevitable danger of contusion and laceration which must 
follow, constitute one of the chief objections to the operation. Its 



THE VECTIS — THE FILLET. 



483 



Fig. 166. 



value as a tractor must always be limited, and quite inferior to that 
of the forceps, while it is as difficult to introduce and manipulate. 

Cases in which it is Applicable. — The vectis has been recommended 
in cases in which the low forceps operation is suitable, provided the 
pains have not entirely ceased. There is no doubt that it may be 
quite capable of overcoming a slight impediment to the passage of 
the head. It is applied over various parts of the head, 
most commonly over the occiput, in the same manner, 
and with the same precautions, as one blade of the 
forceps. Dr. Kamsbotham saj^s "we shall find it 
necessary to apply it to different parts of the cranium, 
and perhaps the face also, successively, in order to re- 
lieve the head from its fixed condition, and favor its 
descent." Such an operation obviously requires quite 
as much dexterity as the application of the forceps; 
while, if we bear in mind its comparatively slight 
power, and the risk of injury to the maternal struc- 
tures, we must admit that the disuse of the instrument 
in modern practice is amply justified. 

The vectis may, however, find a useful application 
when employed to rectify malpositions, especially in 
certain occipito-posterior presentations. This action 
of the instrument has already been considered (p. 308), 
and, under such circumstances, it may prove of. ser- 
vice where the forceps is inapplicable. When so em- 
ployed it is passed carefully over the occiput, and, 
while the maternal structures are guarded from injury, downward 
traction is made during the continuance of a pain. So used, its 
application is perfectly simple and free from clanger, and for this 
purpose it may be retained as a part of the obstetric armamentarium. 

The fillet is the oldest of obstetric instruments, having been fre- 
quently employed before the invention of the forceps, and even in 
the time of Smellie it was much used in the metropolis. It has 
since completely fallen out of favor as a scientific instrument, although 
its use is every now and again advocated, and it is certainly a favorite 
instrument with some practitioners. This is to be explained by the 
apparent simplicity of the operation, and the fact that it can gene- 
rally be performed without the knowledge of the patient; the latter, 
however, is one strong reason why it should not be used. 

Nature of the Instrument. — The fillet consists, in its most improved 
form (that which is recommended by Dr. Eardley Wilniot 1 (Fig. 167), 
of a slip of whalebone fixed into a handle, composed of two separate 
halves, which join into one. The whalebone loop is slipped over 
either the occiput or face, and traction used at the handle. 

Objections to its Use. — When applied over the face, after the head 
has rotated, it would probably do no harm ; but if it were so placed 
when the head was high in the pelvis, traction would necessarily 
produce extension of the chin before the proper time, and would 



Vectis -with. 
Hinged Handle. 



Obst. Trans., vol. xv. 



484 



OBSTETKIC OPERATIONS. 



Fig. 167 thus interfere with the natural mechanism 

of delivery. If placed over the occiput, it 
is impossible to make traction in the direc- 
tion of the pelvic axes, as the instrument 
will then infallibly slip. If traction be 
made in any other direction, there must 
be a risk of injuring the maternal struc- 
tures, or of changing the position of the 
head. Hence there is every reason for dis- 
carding the fillet as a tractor, or as a sub- 
stitute for the forceps, even in the simplest 
cases. 

It is quite possible that it may find a 
useful application in certain cases in which 
the vectis maj also be used, viz., as a rec- 
tifier of malposition, and, from the com- 
parative facility of its introduction, it 
would probably be the preferable instru- 
ment of the two. 

[The whalebone fillet was the great 
weapon of delivery in old Japanese ob- 
stetrics, and according to their obstetrical 
plates must have done fearful execution, 
especially when placed over the body of the foetus, and operated 
upon by a windlass. Fortunately for the native women, science is 
introducing a more rational method. — Ed.] 




Wilmot's 



CHAPTEE V. 



OPERATIONS INVOLVING DESTRUCTION OF THE FCETUS. 



Operations involving the destruction and mutilation of the child 
were among the first practised in midwifery. Craniotomy was evi- 
dently known in the time of Hippocrates, as he mentions a mode of 
extracting the head by means of hooks. Celsus describes a similar 
operation, and was acquainted with the manner of extracting the 
foetus in transverse presentations by decapitation; similar procedures 
were also practised and described by Aetius and others among the 
ancient writers. The physicians of the Arabian school not only 
employed perforators for opening the head, but were acquainted with 
instruments for compressing and extracting it. 

Religious Objections to Craniotomy. — Until the end of the seven- 
teenth century this class of operation was not considered justifiable 



OPERATIONS INVOLVING DESTRUCTION OF F(ETUS. 485 

in the case of living children; it then came to be cliscnssed whether 
the life of the child might not be sacrificed to save that of the mother. 
It was authoritatively ruled by the Theological Faculty of Paris, that 
the destruction of the child in any case was mortal sin. "Si l'on ne 
peut tirer l'enfant sans le tuer, on ne pent sans peche mortel le tirer." 
This dictum of the Roman Church had great influence on Continental 
midwifery, more especially in France, where, up to a recent elate, the 
leading obstetricians considered craniotomy to be only justifiable when 
the death of the foetus had been positively ascertained. Even at the 
present day there are not wanting practitioners who, in their praise- 
worthy objection to the destruction of a living child, counsel delay 
until the child has died; a practice thoroughly illogical, and only 
sparing the operator's feelings at the cost of greatly increased risk to 
the mother. In England, the safety of the child has always been 
considered subservient to that of the mother; and it has been ad- 
mitted that, in every case in which the extraction of a living foetus 
by any of the ordinary means is impossible, its mutilation is perfectly 
justifiable. 

Unjustifiable Frequency. — It must be admitted that the frequency 
with which craniotomy has been performed in this country constitutes 
a great blot on British midwifery. During the mastership of Dr. 
Labbat, at the Rotunda Hospital, the forceps was never once applied 
in 21,867 labors. Even in the time of Clarke and Collins, when its 
frequency was much diminished, craniotomy was performed three or 
four times as often as forceps delivery. These figures indicate a 
destruction of foetal life which we cannot look back to without a 
shudder, and which, it is to be feared, justify the reproaches which 
our Continental brethren have cast upon our practice. Fortunately, 
professional opinion has now completely recognized the sacred duty 
of saving the infant's life, whenever it is practicable to do so; and 
British obstetricians now teach, as carefully as those of any other 
nation, the imperative necessity of using every endeavor to avoid 
the destruction of the foetus. 

Division of the Subject. — The operation now under consideration 
may be necessary: 1st, when the head requires either to be simply 
perforated, or afterwards more completely broken up and extracted ; 
an operation which has received various names, but is generally 
known in this country as craniotomy, and which may or may not 
require to be followed by further diminution of the trunk. 2dly, 
when the arm presents, and turning is impossible; this necessitates 
one of two procedures, decapitation with the separate extraction of 
the body and head, or evisceration. In both classes of cases similar 
instruments are employed, and those generally in use at the present 
time may be first briefly described. 

Description of Instruments Employed. — 1. The object of the perfo- 
rator is to pierce the skull of the child, so as to admit of the brain 
being broken up, and the consequent collapse and diminution in size 
of the cranium. The perforator invented by Den man, or some modi- 
fication of it, has been principally employed. It requires the handles 
to be separated in order to open the blades, and this cannot be done 



486 



OBSTETRIC OPERATIONS. 



by the operator himself. This difficulty is overcome in the modifi- 
cation of Naegele's perforator used in Edinburgh, in which the 
handles are so constructed that they open the points when pressed 
together, and are separated by a steel rod, with a joint at its centre, 
to prevent their opening too soon. By this arrangement the instru- 
ment can be manipulated by one hand only. The sharp-pointed 
portion has an external cutting edge, with projecting shoulders at 
its base, to prevent its penetrating too far into the cranium. Many 
modifications of these arrangements have since been contrived (Figs. 
168, 169, 170). l In some parts of the Continent and America a 



Fig. 168. 



Fig. 169. 



Fig. 170. 




Various forms of Perforators. 



perforator is used constructed on the principle of the trephine; but 
this is vastly more difficult to work, and has the great disadvantage 
of simply boring a hole in the skull, instead of splitting it up, as is 
done by the sharp-pointed instrument. 

The instruments for extraction are the crotchet and craniotomy 
forceps. 

Crotchets and Craniotomy Forceps. — The crotchet is a sharp-pointed 
hook of highly-tempered steel, which can be fixed on some portion 
of the skull, either internal or external, traction being made by the 
handle. The shank of the instrument is either straight or curved 
(Figs. 171 and 172), the latter being preferable, and it is either at- 
tached to a wooden handle or forged in a single piece of metal. [The 



[ l The perforator of Meigs is simply the ordinary tapping trocar with a long handle. 
The trepan-perforator appears to have been first used by Assalini, of Italy, who was 
soon followed by Jorg, of Nnrnberg. Braun, of Vienna, invented an instrument 
with a curved tube and crank handle, which has been introduced here as a curiosity. 
E. Martin, of Berlin, has contrived a straight stemmed trephine of small size. Weiss 
and Son, of London, have improved the Braun perforator, and we have seen it hce 
but it is a mistake to suppose that these instruments have been adopted in our country .\ 
What is most sold is the perforating scissors (Fig. 170). — Ed.] 



OPERATIONS INVOLVING DESTRUCTION OF F(ETUS. 



487 



crotchet should be guarded, to save the mother from risk of lacera- 
tion in case it should slip. — Ed.] A modification of this instrument 
is known as Oldham's vertebral hook. It consists of a slender hook, 
measuring, with its handle, 13 inches in length, which is passed 
through the foramen magnum, and fixed in the vertebral canal, so 
as to secure a firm hold for traction. All forms of crotchets are open 
to the serious objection of being liable to slip, or break through the 
bone to which they are fixed, so wounding either the soft parts of 
the mother, or the fingers of the operator placed as a guard. Hence 
they are discountenanced by most recent writers, 
and may with propriety be regarded as obsolete Figs. 171, 172. 
instruments. 

Craniotomy Forceps are preferable for Extraction. 
— Their place as tractors is well supplied by the 
more modern craniotomy forceps (Fig. 173). These 
are intended to lay hold of the skull, one blade being 
introduced within the cranium, the other externally, 
and, when a firm grasp has been obtained, down- 
ward traction is made. A second object it fulfils 
is, to break away and remove portions of the skull, 
when perforation and traction alone are insufficient 
to effect delivery. Many forms of craniotomy for- 
ceps are in use ; some armed with formidable teeth, 
others, of simpler construction, depending on their 
roughened and serrated internal surfaces for firm- 
ness of grasp. For general use, there is no better 
instrument than the cranioclast of Sir James Simp- 
son (Fig. 174), which admirably fulfils both these 
indications. It consists of two separate blades, 
fastened by a button joint. The extremities of the 
blades are of a duck-billed shape, and are sufficiently 
curved to allow of a firm grasp of the skull being- 
taken ; the upper blade is deeply grooved to allow 
the lower to sink into it, and this gives the instru- 
ment great power in fracturing the cranial bones, 
when that is found to be necessary. It need not, however, be em- 
ployed for the latter purpose, and, the blades being serrated on their 
under surface, form as perfect a pair of craniotomy forceps as any in 
ordinary use. Provided with it, we are spared the necessity of pro- 
curing a number of instruments for extraction. 

Cephalotribe. — Amongst modern improvements in midwifery there 
are few which have led to more discussion than the use of the 
cephalotribe. 1 The instrument, originally invented by Baucleloccjue, 
was long employed on the Continent before it was used in this country, 
the prejudice against it being no doubt due to its formidable size and 
appearance. Of late years many of our leading obstetricians have 
used it in preference either to the crotchet or craniotomy forceps, and 



%J 



Crochets. 



1 [Assalini's "Forcipe Comjiressore,' 
Cephalotribe. — Ed.] 



was in use twenty years before Baudelocque's 



488 OBSTETRIC OPERATIONS. 

have materially modified and improved its construction, so that the 
most objectionable features of the older instruments are not entirely 
removed. 

Object of the Instrument. — The omphalotribe consists of two power- 
ful solid blades, which are applied to the head after perforation, and 
approximated by means of a screw so as to crush the cranial bones, 
and after this it may be also used for extraction. The peculiar value 
of the instrument is, that, when properly applied, it crushes the firm 
basis of the skull, which is left untouched by craniotomy, or, if it 
does not, it at least causes the base to turn edgeways within the 

Fig. 173. Fig. 174. 





Craniotomy Forceps, Simpson's Cranioclast. 

blades, so as to be in a more favorable position for extraction. An- 
other and specially valuable property is, that it crushes the bones 
within the scalp, which forms a most efficient protective covering to 
their sharp edges; in this way one of the principal dangers of crani- 
otomy — the wounding of the maternal passages by spicuhe of bone — ■ 
is entirely avoided. 

The cephalotribe, therefore, acts in two ways ; as a crusher, and 
as a tractor. Some obstetricians believe the former to be its more 
important use, and even maintain that the cephalotribe is unsuited 
for traction. This view is specially maintained by Pajot, who teaches 
that, after the size of the skull has been diminished by repeated 
crushings, its expulsion should be left to the natural powers. There 
are some grounds for believing that in the greater degrees of obstruc- 
tion the tractile power of the instrument should not be called into 
use; but, in the large majority of cases, the facility with which the 
crushed head may be withdrawn by it constitutes one of its chief 
claims to the attention of the obstetrician. No one who has used it 
in this way, and experienced the rapid and easy manner in which it 
accomplishes delivery, can have any doubt on this point. 



OPERATIONS INVOLVING DESTRUCTION OF ECETUS. 



489 



Fig 



Its Value. — There is every reason to believe that cephalotripsy 
will be much extended in this country, and that it will be considered, 
as I believe it unquestionably deserves to be, the ordinary operation 
in cases requiring destruction of the foetus. The comparative merits 
of cephalotripsy and craniotomy will be subsequently considered. 

Description of the Instrument. — The most perfect cephalotribe is 
probably that known as Braxton Hicks's (Fig. 175), which is a modi- 
fication of Simpson's. It is not of 
unwieldy size, but sufficiently power- 
ful for any case, and not extravagant 
iu price. The blades have a slight 
pelvic curve, which materially facili- 
tates their introduction, yet not suffi- 
ciently marked to interfere with their 
being slightly rotated after applica- 
tion. Dr. Kidd, of Dublin, prefers a 
straight blade ; while Dr. Matthews 
Duncan thinks it better to use a some- 
what bulkier instrument, modelled on 
the t} T pe of the Continental cephalo- 
tribes. The principle of action of all 
these is identical, and their differences 
are not of very material importance. 

Section r of the Skull by the Forceps- 
saw, or Ecraseur. — Another mode of 
diminishing- the foetal skull is bv re- 
moving it in sections. This object is 
aimed at in the forceps-saw of Van 
Huevel, which consists of two large 
blades, not unlike those of the cepha- 
lotribe in appearance. Within these 
there is a complicated mechanism, 
working a chain saw from below up- 
wards, which cuts through the foetal 
skull; the separated portions are sub- 
sequently withdrawn piecemeal. This 
instrument is highly spoken of by the 
Belgian obstetricians,who believe that 
it affords by far the safest and most effectual wa} r of reducing the 
bulk of the foetal skull. In this country it is practically unknown : 
and, although it must be admitted to be theoretically excellent, the 
complexity and cost of the apparatus have always stood in the way 
of its being used. 

Dr. Barnes has suggested that the same results may be obtained 
by dividing the head with a strong wire ecraseur. So far as I know, 
this suggestion has never yet been carried out in practice, not even 
by himself, and, therefore, it is not possible to say much about it. I 
should imagine, however, that there would be considerable difficulty 
in satisfactorily passing the loop of wire over the skull, in a pelvis 
in which there is any well-marked deformity. 
32 




Hicks's Cephalotribe. 



490 OBSTETRIC OPERATIONS. 

Cases requiring Craniotomy. — The most common cause for which 
craniotomy or cephalotripsy is performed, is a want of proper pro- 
portion between the head and the maternal passages. This may 
arise from a variety of causes. The most important, and that most 
often necessitating the operation, is osseous deformity. This may 
exist either in the brim, cavity, or outlet, and it is most often met 
with in the antero-posterior diameter of the brim. Obstetric au- 
thorities differ considerably as to the precise amount of contraction 
which will prevent the passage of a living child at term. Thus 
Clarke and Barns believe that a living child cannot pass through a 
pelvis in which the antero-posterior diameter at the brim is less than 
3 \ inches. Eamsbotham fixes the limit at 3 inches, and Osborne and 
Hamilton at 2f inches. The latter is the extreme limit at which the 
birth of a living child is possible ; but there can be no doubt that, 
under favorable circumstances, it may be possible to draw the foetus, 
after turning, through a pelvis of that size. The opposite limit of 
the operation is still more open to discussion. Various authorities 
have considered it quite possible to draw a mutilated foetus through 
a pelvis in which the antero-posterior diameter does not exceed 1J 
inches, and, indeed, have succeeded in doing so. But then there 
must be a fair amount of space in the transverse diameter of the 
pelvis to admit of the necessary manipulations. If there be a clear 
space here of 3 inches and upwards, it is no doubt possible to deliver 
per vias naturales ; but in such extreme deformities, the difficulties 
are so great, and the bruising of the maternal structures so extensive, 
that it becomes an operation of the greatest possible severity, with 
results nearly as unfavorable to the mother as the Cesarean section. 
Hence some Continental authorities have not scrupled to prefer the 
latter operation in the worst forms of pelvic deformity. The rule in 
English practice always has been that craniotomy must be performed 
whenever it is practicable ; and there can be no doubt that it is the 
right one. [The operation may be practicable, and still be more 
dangerous than the Cesarean section. Where experience shows this 
to be the case, we should in the United States elect the latter and 
perform it early. — Ed.] 

Limits of the Operation. — Between from 2f to 3 inches antero-pos- 
terior diameter in the one direction, and If inches in the other, may 
be said to be the limits of craniotomy, provided, in the latter case, 
there be a fair amount of space in the transverse diameter. The 
same limits may be laid down with regard to tumors or other sources 
of obstruction. 

Other Causes justifying Craniotomy. — There are a few other con- 
ditions in which craniotomy is justifiable, independently of pelvic 
contraction, such as certain conditions of the soft parts which are 
supposed to render the passage of the head peculiarly dangerous to 
the mother. Among them may be mentioned swelling and inflam- 
mation of the vagina from the length of the previous labor, bands 
and cicatrices in the vagina, and occlusion and rigidity of the os. It 
is hardly too much to say that with a proper use of the resources of 
midwifery, the destruction of a living foetus for any of these condi- 



OPERATIONS INVOLVING DESTRUCTION OF FOETUS. 491 

tious might be obviated. The most common of them is undoubtedly 
swelling of the soft parts causing impaction of the head ; an occur- 
rence which ought to be invariably prevented by a timely use of the 
forceps. Should interference unfortunately be delayed until impac- 
tion has actually taken place, doubtless no other resource but crani- 
otomy would be left ; but such cases, it is to be hoped, are now of 
rare occurrence in British practice. Undue rigidity of the os can be 
overcome by dilatation with the caoutchouc bags, or, in more serious 
cases, by incision, which would certainly be less perilous to the 
mother than dragging even a mutilated foetus through the small and 
rigid aperture. In the case of bands and cicatrices in the vagina, 
dilatation or incision will generally suffice to remove the obstruction; 
but even were this not so, here, as in excessive rigidity of the peri- 
neum, it would be better that slight lacerations should take place, 
than that the child should be killed. 

Complications of Labor justifying Craniotomy. — Certain complica- 
tions of labor are held to justify craniotomy, such as rupture of the 
uterus, convulsions, and hemorrhage. The application of the forceps 
or turning will generally answer our purpose equally well, especially 
as we have the means of dilating the os sufficiently to admit of one 
or other of them being performed, when the natural dilatation is not 
sufficient. Craniotomy in rupture of the uterus will also be rarely 
indicated, as we have seen that gastrotomy appears to afford a better 
chance to the mother in those cases in which the foetus has partially 
or entirely escaped from the uterine cavity. 

Excessive Size of the Foetus. — Want of proportion between the foetus 
and the pelvis, depending on undue size of the head, either natural, 
or the result of disease, may render the operation essential. In the 
former of these cases we shall generally have first attempted delivery 
with the forceps, and, if it has failed, there can be no doubt as to the 
propriety of lessening the bulk of the head by perforation. 

Craniotomy when the Child is believed to be Dead. — In most obstetric 
works we are recommended to perforate, rather than apply the for- 
ceps, when we are convinced that the child has ceased to live. This 
advice is based on the greater facility with which craniotomy can 
be performed, and its supposed greater safety to the mother. There 
can be no doubt of the ease with which the child can be extracted 
after perforation, when the pelvis is not contracted; and, if Ave could 
always be sure of our diagnosis, the rule might be a good one. Be- 
fore acting on it, however, we must bear in mind the extreme diffi- 
culty of positively ascertaining the death of the foetus. Of the signs 
usually relied on for this purpose, there are scarcely any which are 
not open to fallacy, except peeling of the scalp, and disintegration of 
the cranial bones (which do not take place unless the child has been 
dead for a length of time), and they are, therefore, useless, in most 
instances. Discharge of the meconium constantly takes place when 
the child is alive; a cold and pulseless prolapsed cord may belong to 
a twin; and the foetal heart may become temporarily inaudible, 
although the child is not dead. If, indeed, we have carefully watched 
the foetal heart all through the labor, and heard it become more and 



492 



OBSTETRIC OPERATIONS 



Fig. 176. 



more feeble, and finally stop altogether, we might be certain that the 
child has died; but surely such observations would rather indicate 
an early recourse to the forceps or version, so as to obviate the fatal 
result we know to be impending. 

In certain breech presentations, or after turning, it may be found 
impossible to extract the head, without diminishing its size by per- 
forating behind the ear. In such cases we know to a certainty 
whether the child be alive or dead, before resorting to the operation. 
The first step, whether we resort to cephalotripsy or craniotomy, 
is perforation, which will, therefore, be first described. In the former 
the desirability of first perforating the head is not always recognized. 
To endeavor to crush the head without perforating is needlessly to 
increase the difficulties of the case, and it should be remembered, as 
a cardinal rule, that perforation is an essential preliminary to the 
proper use of the cephalotribe. 

Method of Perforation. — Before perforating we must carefully ascer- 
tain the exact relation of the os to the presenting part, since, in many 

cases, the operation is performed 
before the os is fully dilated, when 
there is a risk of wounding the 
cervix. Two or more fingers of 
the left hand should be passed up 
to the head, and placed against the 
most prominent part of the parietal 
bone. Under these, used as a guard 
(Fig. 176), the perforator should be 
cautiously introduced until the 
scalp is reached. It is important 
to fix on a bony part of the skull, 
and not on a suture or fontanelle, 
for puncture, because our object 
is to break up the vault of the 
cranium as much as possible, so 
as to allow the skull to collapse. 
When the instrument has reached 
the point we have selected, it should 
be made to penetrate the scalp and 
skull with a semi-rotatory boring 
motion, and advanced until it has 
sunk up to the rests, which will 
oppose its further progress. Occa- 
sionally considerable force will be 
necessary to effect penetration, 
more especially if the scalp be 
swollen by long-continued pres- 
sure; and this stage of the opera- 
tion will be facilitated by causing an assistant to steady the head by 
pressure on the foetus through the abdomen, more especially if it be 
still free above the pelvic brim. We must then press together the 
handles of the instrument, which will have the effect of widely 




Perforation of the Skull. 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 493 

separating the cutting portion, and making an incision through the 
bones. After this the point should be turned round, and again 
opened at right angles to the former incision, so as to make a free 
crucial opening. During this process care must be taken to burj 
the perforator in the skull up to the rests, so as to avoid the possi- 
bility of injuring the maternal soft parts. The instrument should 
now be introduced within the skull and moved freely about, so as 
to thoroughly and completely break up the brain. Especial care 
must be taken to reach the medulla oblongata and base of the brain, 
for, if these were not destroyed, we might subject ourselves to the 
distress of extracting a child in whom life was not extinct. If this 
part of the operation be thoroughly performed, there will be no 
necessity for washing out the brain by the injection of warm water, 
as is sometimes recommended, for the broken-up tissue will escape 
freely through the opening made by the perforator. 

Perforation of the After-coming Head. — The perforation of the 
after-coming head does not generally offer any particular difficulty. 
It is accomplished in the same manner, the child's body being well 
drawn out of the way by an assistant. The point of the perforator, 
carefully guarded by the finger, is guided up to the occiput, or behind 
the ear, where it is inserted. 

It is sometimes useful to Postpone Extraction. — If there be no neces- 
sity for yqtj rapid delivery, and the pains be still present, it is often 
advisable to wait ten minutes or a quarter of an hour before pro- 
ceeding to extract. This delay will allow the skull to collapse and 
become moulded to the cavity of the pelvis, when forced down by 
the pains, and possibly the natural efforts may suffice to finish the 
labor in that time ; or, at least, the head will have descended further, 
and will be in a better' position for extraction. Should perforation 
be required after having failed to deliver with the forceps — and this 
is only likely to be the case when the obstruction is comparatively 
slight — it is certainly a good plan to perforate without removing the 
forceps, which may then be used as tractors. 

We have now to decide on the method of extraction, and our 
choice lies between the cephalotribe and the craniotomy forceps. 

Comparative merits of Omphalotripsy and Craniotomy. — Those who 
have used both must, I think, admit that in any ordinary case, in 
which the obstruction is not great, and only a comparatively slight 
diminution in the size of the head is required, cephalotripsy is infi- 
nitely the easier operation. The facility with which the skull can 
be crushed is sometimes remarkable, and those who will take the 
trouble to read the reports of the operation published by Braxton 
Hicks, Kidd, and others, cannot fail to be struck with the rapidity 
with which the broken-down head may often be extracted. This is 
far from being the case with the craniotomy forceps, even when the 
obstruction is moderate only; for it may be necessary to use conside- 
rable traction, or the blades may take a proper grasp with difficulty, 
or it may be essential to break down and remove a considerable 
portion of the vault of the cranium before the head is lessened suffi- 
ciently to pass. During the latter process, however carefully per- 



494 OBSTETRIC OPERATIONS. 

formed, there is a certain risk of injuring the maternal structures, 
and, in the hands of a nervous or inexperienced operator, this dan- 
ger, which is entirely avoided in cephalotripsy, is far from slight. 
The passage of the blades of the cephalotribe is by no means difficult, 
and I think it must be admitted that the possible risks attending it 
are comparatively small. On account, therefore, of its simplicity and 
safety to the maternal structures, I believe cephalotripsy to be de- 
cidedly the preferable operation in all cases of moderate obstruction. 

When we approach the lower limit, and have to do with a very 
marked amount of pelvic deformity, the two operations stand on a 
more equal footing. Then the deformity may be so great as to render 
it difficult to pass the blades of even the smallest cephalotribe suffi- 
ciently deep to grasp the head firmly, and, even when they are passed, 
the space is often so limited as to impede the easy workiug of the 
instrument. Besides this, repeated crushings may be required to 
diminish the skull sufficiently. I attach but little importance to the 
argument that the diminution of the skull in one diameter increases 
its bulk in another. The necessity of removing and replacing the 
blades on another part of the skull, and of repeating this perhaps 
several times, in the manner recommended by Pajot, is a far more 
serious objection. To do this in a contracted pelvis involves, of 
necessity, the risk of much contusion. Fortunately cases of this kind 
are of extreme rarity, much more so than is generally believed, but 
when they do occur they tax the resources of the practitioner to the 
utmost. 

On the whole, the conclusion I would be inclined to arrive at with 
regard to the two operations is, that in all ordinary cases, cephalo- 
tripsy is safer and easier, whereas in cases with cousiderable pelvic 
deformity, the advantages of cephalotripsy are not so well marked, 
and craniotomy may even prove to be preferable. 

Description of the Operation. — The first step in using the cephalo- 
tribe is the passage of the blades. These are to be inserted in pre- 
cisely the same manner, and with the same precautions, as in the 
high forceps operation. In many cases the os is not fully dilated, 
and it is absolutely essential to pass the instrument within it. Special 
care should, therefore, be taken to avoid any injury to its edges, and, 
for this purpose, two or three fingers of the left hand, or even the 
whole hand, should be passed high up, so as thoroughly to protect 
the maternal structures. In order that the base of the skull may be 
reached and effectually crushed, the blades must be deeply inserted, 
and, in doing this, great care and gentleness must be used. As the 
projecting promontory of the sacrum generally tilts the head for- 
wards, the handles of the instrument, after locking, must be well 
pressed back towards the perineum. If the blades do not lock easily, 
or if any obstruction to their passage be experienced, one of them must 
be withdrawn and re-introduced, just as in forceps operations. Care 
mast be taken, as the instrument is being inserted, to fix and steady 
the head by abdominal pressure, since it is generally far above the 
brim, and would readily recede if this precaution were neglected. 
"When the blades are in situ, we proceed to crush by turning the 
screw slowly, and, as the blades are approximated, the bones yield, 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 



495 



Fig. 17 



and the cephalotribe sinks into the cranium. The crushed portion 
then measures, of course, no more than the thickness of the blades, 
that is about 1J inches. This is necessarily accompanied by some 
bulging of the part of the cranium that is not within the grasp of 
the instrument (Fig. 177), but in slight 
deformity this is of no consequence, and 
we may proceed to extraction, waiting, if 
possible, for a pain, and drawing down- 
wards in the axis of the pelvic outlet, as 
in forceps delivery. The site of perfora- 
tion should be examined to see that no 
spiculae of bone are projecting from it, and 
if so they should be carefully removed. 
In such cases the head often descends at 
once, and with the greatest ease. Should 
it not do so, or should the obstruction be 
considerable, a quarter turn should be 
given to the handles of the instrument, 
so as to bring the crushed portion into 
the narrowed diameter, and the uncrushed 
portion into the wider transverse diameter. 
It may now be advisable to remove the 
blades carefully, and to reintroduce them 
with the same precautions, so as to crush 
the unbroken portion of the skull. This 
adds materially to the difficulties of the 
case, since the blades have a tendency to 
fall into the deep channel already made 
in the cranium, and so it is by no means 
always easy to seize the skull in a new 
direction. Before reapplying them, if the 
condition of the patient be good and pains 
be present, it may be well to wait an hour 
or more, in the hope of the head being 
moulded and pushed down into the pelvic 
cavity. This was the plan adopted by Dubois, and, according to 
Tarnier, was the secret of his great success in the operation. Pajot's 
method of repeated crushings, in the greater degrees of contraction, 
is based on the same idea, and he recommends that the instrument 
should be reintroduced at intervals of two, three, or four hours, 
according to the state of the patient, until the head is thoroughly 
crushed ; no attempts at traction being used, and expulsion being 
left to the natural powers. This, he says, should always be done 
when the contraction is below 2J inches, and he maintains that it is 
quite possible to effect delivery by this means when there is only 1J 
inches in the antero-posterior diameter. The repeated introduction 
of the blades in this fashion must necessarily be hazardous, except 
in the hands of a very skilful operator ; and I believe that if a 
second application fail to overcome the difficulty, which will only be 
very exceptionally the case, that it would be better to resort to the 
measures presently to be described. 




Foetal Head crushed by the 
Cephalotribe. 



496 



OBSTETRIC OPERATIONS. 



Fig 



Fig. 179. 



Should we elect to trust to the craniotomy forceps for extraction, 
one blade is to be introduced through the perforation, and the other, 
in apposition to it, on the outside of the scalp. In moderate deformi- 
ties, traction applied during the pains may of itself suffice to bring 
down the head. Should the obstruction be too great to admit of 
this, it is necessary to break clown and remove the vault of the 
cranium. For this purpose Simpson's cranioclast answers better 
than any other instrument. One of the blades is passed within the 
cranium, the other, if possible, between the scalp and the skull, and 
the portion of bone grasped between them is then broken off; this 
can generally be accomplished by a twisting motion of the wrist, 
without using much force. The separated portion of bone is then 
extracted, the greatest care being taken to guard the maternal struc- 
tures, during its removal, by the fingers of the left hand. The in- 
strument is then applied to a fresh part of the skull, and the same 
process repeated, until as mnch of the vault of the cranium as may 
be necessary is broken up and removed. 

[The craniotomy forceps chiefly in use with us were devised by 
the late Prof. Charles D. Meigs, for his second operation upon Mrs. 
Eeybold, of Philadelphia, in 1833, and have 
been used repeatedly since, either as tractors, 
or for reducing the size of the foetal head, in 
cases of deformity of the pelvis. 2 Some obste- 
tricians prefer the less curved, and broader- 
bladed instrument of Great Britain, as a trac- 
tor ; but for the general purposes of picking 
away the cranial bones, and drawing down the 
base of the skull, in cases of extreme pelvic 
deformity, there is no more simple appliance 
than that of Dr. Meigs. 

To act upon an oval body like the foetal 
head, Dr. M. was obliged to prepare two forms 
of forceps — straight and curved — to be used 
as might be required, according to the part of 
the skull to be broken clown, or drawn upon. 
These are lightly made, serrated, and 12} 
inches in length. — Ed.] 

Advantages of bringing down the Face in 
Difficult Cases. — Dr. Braxton Hicks 1 has con- 
clusively shown that in difficult cases, after 
the removal of the cranial vault, the proper 
procedure is to bring down the face; since the 
smallest measurement of the skull, after the 
removal of the upper part of the cranium, is from the orbital ridge 
to the alveolar edge of the superior maxillary bone. This alteration 
in the presentation he proposes to effect by a small blunt hook, made 




Straight Curved 

Craniotomy Craniotomy 

Forceps. Forceps. 



1 Obst. Trans., vol. vii. 

[ 2 The illustration given is taken from the instruments devised by Dr. Meigs 
as an improvement upon his original pattern, and will be seen to differ from that 
heretofore given in American obstetrical publications. — Ed.] 



OPERATIONS INVOLVING DESTRUCTION OF FGSTUS. 497 

for the purpose, which, is forced into the orbit, by means of which 
the face is made to descend. Barnes recommends that this should 
be done by fixing the craniotomy forceps over the forehead and face, 
and making traction in a backward direction, so as to get the face 
past the projecting promontory of the sacrum. The importance of 
bringing down the face was long ago pointed out by Burns, but it 
had been lost sight of, until Hicks again drew attention to it in the 
paper referred to. In the class of cases in which this procedure is 
valuable, the risk to the maternal passages, from the removal of 
fractured portions of bone, must always be considerable, and it is of 
great importance not only to preserve the scalp as entire as possible, 
so as to protect them, but to use the utmost possible care in removing 
the broken pieces of bone. 

Extraction of the Body. — When the extraction of the head has 
been effected, either by the cephalotribe or the craniotomy forceps, 
there is seldom much difficulty with the body. By traction on the 
head one of the axillae can easily be brought within reach, and if the 
body do not readily pass, the blunt hook should be introduced, and 
traction made until the shoulder is delivered. The same can then be 
done with the other arm. If there be still difficulty, the cephalotribe 
may be used to crushed the thorax. The body is, however, so com- 
pressible that this is rarely required. 

Embryotomy where Turning is Impossible. — There only remains for 
us to consider the second class of destructive operations. These may 
be necessary in long-neglected cases of arm presentation, in which 
turning is found to be impracticable. Here fortunately the question 
of killing the foetus does not arise, since it will, almost necessarily, 
have already perished from the continuous pressure. We have two 
operations to select from, decapitation and evisceration. 

Decapitation. — The former of these is an operation of great an- 
tiquity, having been fully described by Celsus. It consists in sever- 
ing the neck, so as to separate the head from the body ; the body is 
then withdrawn by means of the protruded arm, leaving the head in 
utero to be subsequently dealt with. If the neck can be reached 
without great difficulty — and, in the majority of cases, the shoulder 
is sufficiently pressed down into the pelvis to render this quite possi- 
ble — there can be no doubt, that it is much the simpler and safer 
operation. 

Methods of Dividing the Neck. — The whole question rests on the 
possibility of dividing the neck. For this purpose many instruments 
have been invented. The one generally recommended in this country 
is known as Eamsbotham's hook, and consists of a sharply curved 
hook, with an internal cutting edge. This is guided over the neck, 
which is divided by a sawing motion. There is often considerable 
difficulty in placing the instrument over the neck, although, if this 
were done, it would doubtless answer well. Others have invented 
instruments, based on the principle of the apparatus for plugging 
the nostrils, by means of which a spring is passed round the neck, 
and to the extremity of the spring a short cord, or the chain of an 
e*craseur, is attached ; the spring is then withdrawn and brings the 



498 OBSTETRIC OPERATIONS. 

chain or cord into position. The objection to any of these appa- 
ratuses is, that they are unlikely to be at hand when required, for 
few practitioners provide themselves with costly instruments which 
they may never require. It is of importance, therefore, that we 
should have at our command some means of dividing the neck, which 
is available in the absence of any of these contrivances. Dubois re- 
commends for this purpose a strong pair of blunt scissors. The neck 
is brought as low as possible by traction on the prolapsed arm, and 
the blades of the scissors guided carefully up to it. By a series of 
cautious snipping movements it is then completely divided from 
below upwards. This, if the neck be readily within reach, can gen- 
erally be effected without any particuiar difficulty. Dr. Kidd, of 
Dublin, 1 who strongly advocates this operation, recommends that an 
ordinary male elastic catheter, strongly curved and mounted on a firm 
stilet, or, still better, on a uterine sound, should be passed round the 
neck. Previous to introduction a cord should be attached to the ex- 
tremity of the catheter, which is left round the neck when it is with- 
drawn. By means of this cord a strong piece of whipcord, or the 
wire of an ecraseur, can easily be drawn round the neck and used 
for dividing it. The former, to protect the maternal structures, 
may be worked through a speculum, and by a series of lateral 
movements the neck is easily severed. The ecraseur, however, offers 
special advantages, since it entirely does away with any risk of in- 
juring the mother. 

Withdrawal of the Body and Delivery of the Head. — After the neck 
is divided the remainder of the operation is easy. The body is 
withdrawn without difficulty by the arm, and we then proceed to 
deliver the head. By abdominal pressure this, in most cases, can be 
pushed down into the pelvis, so as to come easily within reach of 
the cephalotribe, which is by far the best instrument for extraction. 
Preliminary perforation is not necessary, since the brain can escape 
through the severed vertebral canal. The secret of doing this easily 
is to fix and press down the head sufficiently from above, otherwise 
it would slip away from the grasp of the instrument. The perfora- 
tor and craniotomy forceps may be used, if the cephalotribe be not 
at hand. Perforation is, however, by no means always easy, on ac- 
count of the mobility of the head. After it is accomplished one 
blade of the craniotomy forceps is passed within the skull, the other 
externally, and the head slowly drawn down. 

Evisceration. — The alternative operation of evisceration is a much 
more troublesome and tedious procedure, and should only be used 
when the neck is inaccessible. The first step is to perforate the 
thorax at its most depending part, and to make as wide an opening 
into it as possible, in order to gain access to its contents. Through 
this the thoracic viscera are removed piecemeal, being first broken 
up as much as possible by the perforator, and then, the diaphragm 
being penetrated, those in the abdomen. The object is to allow the 
body to collapse, and the pelvic extremities to descend, as in sponta- 

1 Dublin Quart. Journ., May, 1871. 






CESAREAN SECTION. 499 



neous evolution. This can be much facilitated by dividing the spinal 
column with a strong pair of scissors, introduced into the opening 
made in the thorax, so that the body may be doubled up as on a 
hinge. Here the crotchet may find a useful application, for it can 
be passed through the abdominal cavity, and fixed on some point in 
the interior of the child's pelvis ; and thus strong traction can be 
made without any risk of injury to the mother. It can be readily 
understood that this process is so lengthy and difficult as to render 
it probably the most trying of obstetric operations • it is certainly 
inferior in every respect to decapitation, and is only to be resorted 
to when that is impracticable. 

[In seven instances of impaction of the foetus in a transverse posi- 
tion, in the United States, the Cesarean operation has been per- 
formed, owing to great difficulty in accomplishing either decapitation 
or evisceration, and five of the women were saved. The two deaths 
were from exhaustion. — Ed.] 



CHAPTEE VI. 

THE (CESAREAN SECTION — SYMPHYSEOTOMY — AND LAPARO- 
ELYTROTOMY. 

History. — The Csesarean section has perhaps given rise to more 
discussion than any other subject connected with midwifery, and 
there is yet much difference of opinion as to the limits of, and indica- 
tions for, the operation. The period at which the Caesarean section 
was first resorted to is not known with accuracy. It seems to have 
been practised by the Greeks, after the death of the mother; and 
Pliny mentions that Scipio Africanus and Manlius were born in this 
way. The name of Caesar is said to have been given to children so 
extracted, and afterwards to have been assumed as a family patro- 
nymic. These children were dedicated to Apollo; whence arose the 
practice of things sacred to that god being taken under the special 
protection of the family of the Caesars. Many celebrities have been 
supposed to owe their lives to the operation ; among the rest ^Escula- 
pius, Julius Caesar, and our own Edward VI. Eegarding the two 
latter, there is conclusive proof that the tradition is without founda- 
tion. There is no doubt that the operation was constantly practised 
on women who had died at an advanced period of pregnancy, and 
indeed it has, at various times, been enforced by law. Thus among 
the Romans it was decreed by Nurna, that no pregnant woman should 
be buried until the foetus had been removed by abdominal section. 
The Italian laws also made it necessary, and the operation has 



500 OBSTETRIC OPERATIONS. 

always received the strong support of the Eoman Church. So lately 
as the middle of the eighteenth century, the King of Sicily sentenced 
to death a physician who had neglected to practise it. The first 
authentic case in which the operation was performed on a living 
woman occurred in 1491. It was afterwards practised by Nufer in 
1500 ; and in 1581 Eousset published a work on the subject, in which 
a number of successful cases were related. In English works of that 
time it is not alluded to, although it was undoubtedly performed on 
the Continent, and to such an extent that its abuse became almost 
proverbial. We have evidence in Shakespeare, however, that the 
operation was familiarly known in this country, since he tells us 
that — 

. Macduff was from liis mother's womb 
1 Untimely ripped. 

Pare and Guillemeau, amongst the writers of the period, were noted 
for their hostility to the operation , while others equally strongly 
upheld it. 

In this country it has scarcely ever been performed in a manner 
which offers even the faintest hope of success. It has been looked 
upon as almost necessarily fatal to the mother, and it has, therefore, 
been delayed until the patient has arrived at the utmost stage of 
exhaustion. For example, in looking over the records of British 
cases, it is no uncommon thing to find that the Cesarean section was 
resorted to, two, three, or even six days after labor had begun, 2 and 
when the patient was almost moribund. With rare exceptions within 
the last few years, the operation has been performed in what may be 
called a hap-hazard way. In many cases long and fruitless attempts 
at delivery by craniotomy had already been made, so that the pas- 
sages had been subjected to much contusion and violence. Little or 
no attempt has been made to obviate the well-known risks of ab- 
dominal operations ; no care has been taken to prevent blood and 
other fluids finding their way into the peritoneal cavity, and no 
means have been adopted subsequently to remove them. It is, 
therefore, not so much a matter of surprise that the mortality has 
been so great, but rather that any cases have recovered. 

Mortality. — From what we know of the history of ovariotomy, its 
early fatality, and the extreme and even apparently exaggerated 
precautions which are essential to its success, it is fair to conclude 
that, if the Cesarean section were performed, as it is to be hoped it 
always will be in future, with the same careful attention to minute 
details as ovariotomy, the results would not be so disastrous. Making 
every allowance for these facts, it must be admitted that the Cesa- 
rean section is necessarily almost a forlorn hope ; and in making 
these observations I have no intention of contesting the well-estab- 
lished rule of British practice, that it is not admissible as an opera- 

[' The word "untimely" we have always regarded as proof that it did not refer 
to the Caesarean section, which is performed during labor. It more likely refers to 
the goring of a bull or cow, instances of which are upon record. — Ed.] 

2 See Radford on Ciesarean Section, p. 15. 



CESAREAN SECTION. 501 

tion of election, and must only be resorted to when delivery per vias 
naturales is impossible. 

Statistical Returns are not Reliable. — The mortality, as given in 
statistical returns from various sources, differs so greatly as to make 
them but little reliable. Radford tabulates 77 operations performed 
in this countn^, of which 66, or 85.71 per cent., proved fatal, and 11 
or 14.28 per cent., recovered. Michaelis and Kayser found that out 
of 258 and 338 operations, 54 and 64 per cent, respectively were 
fatal. These include operations performed under all sorts of condi- 
tions, even when the patient was almost moribund ; and until we are 
in possession of a sufficient number of cases performed under con- 
ditions showing that the result is obviously due to the operation — • 
in which it was undertaken at an early period of labor, and performed 
with a reasonable amount of care — it is obviously impossible to arrive 
I at any reliable conclusions as to the mortality of the operation. That 
it is necessarily hopeless is certainly not the case, and we know that 
, on the Continent, where it is resorted to much oftener and earlier in 
[ labor than in this country, there are authentic cases in which it has 
been performed twice, thrice, and even, in one instance, four times 
on the same patient. Kayser thinks that a second operation on the 
same patient affords a better prognosis than a first, probably because 
peritoneal adhesions, resulting from the first operation, have shut off 
the general abdominal cavity from the uterine wound ; and he believes 
that in second operations the mortality is not more than 29 per cent. 
Results to the Child. — The mortality of the children likewise cannot 
be ascertained from statistical returns, since, in the large majority of 
cases in which dead children were extracted, the result had nothing 
to do with the operation. Indeed, there is nothing in the operation 
itself which can reasonably be supposed to affect the child. If, there- 
fore, the child be alive when the operation is commenced, there is 
every probability of its being extracted alive; and Radford's conclu- 
sion that, " the risk to infants in Cassarean births is not much greater 
than that which is contingent on natural labor, provided correct prin- 
ciples of practice are adopted," probably very nearly represents the 
I truth. 

Causes requiring the Operation. — The Cesarean section is required 

I when there is such defective proportion between the child and the 

I maternal passages, that even a mutilated foetus cannot be extracted. 

j This in by far the greatest number of cases is due to deformity of 

| the pelvis arising from rickets or mollities ossium. The latter may 

j occur in a patient who has been previously healthy, and who has 

given birth to living children. It is a more common cause of the 

extreme varieties of deformity than rickets, and out of 77 2 British 

cases, tabulated by Radford, in 43 the deformity was produced by 

osteomalacia, and in 14 only by rickets. In certain cases the pelvis 

itself may be of normal size, but has its cavity obstructed by a solid 

[' 98 operations —82 fatal, 16 recovered. 1868.— Ed.] 

[ 2 Out of 98, there were 46 deformed by osteomalacia against 16 by rickets. — 
Ed.] 



502 OBSTETRIC OPERATIONS. 

tumor of the ovary, of the uterus itself, or one growing from the 
pelvic wall. The obstruction may also depend on morbid conditions 
of the maternal soft parts, of which the most common is advanced 
malignant disease of the cervix. Other conditions may, however, 
render it essential. Thus Dr. Newman 1 records a case in which he 
performed the operation for insurmountable resistance and obstruc- 
tion of the cervix, which was believed at the time to be malignant. 
The patient recovered, and was subsequently delivered naturally, 
and without anything abnormal being made out. This renders it 
probable that the disease was not malignant, and it may possibly 
have been an extensive inflammatory exudation into the tissues of 
the cervix, subsequently absorbed. I myself was present at a Cesa- 
rean section performed in Calcutta in the year 1857, when the pelvis 
was so uniformly blocked up with exudation, probably due to exten- 
sive pelvic cellulitis or hsematocele, that the operation was essential. 

Limits of Obstruction justifying the Operation. — Different accou- 
cheurs have fixed on various limits for the operation. Most British 
authorities are of opinion that it need not be resorted to, if the 
smallest diameter of the pelvis exceed 1J inch. This question has 
already been considered in discussing craniotomy, and it has been 
shown that a mutilated foetus may be drawn through a pelvis of 1J 
inch antero-posterior diameter, provided there be a space of 3 inches 
in the transverse diameter. If sufficient space for using the neces- 
sary instruments do not exist, the Csesarean section may be required, 
even when there is a larger antero-posterior diameter than 1J inch. 
This is especially likely to occur when we have to do with deformity 
arising from mollities ossium, in which the obstruction is* in the 
sides and outlet of the pelvis, the true conjugate being sometimes 
even elongated. On the Continent the Cesarean section is constantly 
practised, as an operation of election, when the smallest diameter 
measures from 2 to 2 J inches ; and when the child is known to be 
alive, some foreign authors recommend it when there are as much 
as 3 inches in the antero-posterior diameter. In this country, where 
the life of the child is most properly considered of secondary import ■ 
ance to the safety of the mother, we cannot fix one limit for the ope- 
ration when the child is living, and another when it is dead. Nor, I 
think, can we admit the desire of the mother to run the risk, rather 
than sacrifice the child, as a justification of the operation, although 
this is laid down as an indication by Schroeder. 2 Great as are the 
dangers attending craniotomy in extreme deformity, there can be no 
doubt that we must perform it whenever it is practicable, and only 
resort to the Caesarian section when no other means of delivery are 
possible. 

For this reason. I think it unnecessary to discuss the question, 
whether we are justified in destroying the foetus in several successive 
pregnancies, when the mother knows that it is impossible for her to 
give birth to a living child. Dennian was the first to question the 

1 Obst. Trans., vol. iii. p. 343. 

2 Manual of Midwifery, p. 202. 



CESAREAN SECTION. 503 

advisability of repeating craniotomy on the same patient. Amongst 
modern authors Radford takes the most decided view on this point, 
and distinctly teaches that even when delivery by craniotomy is pos- 
sible, it " can be justified on no principle, and is only sanctioned by 
the dogma of the schools, or by usage," and that, therefore, the 
Cesarean section should be performed with the view of saving the 
child. Doubtless much can be said from this point of view; but, 
nevertheless, he would be a bold man who would deliberately elect 
to perform the Cesarean section on such grounds. 1 It is to be hoped, 
however, that in these days the induction of premature labor or 
abortion would always spare us the necessity of deciding so delicate 
a point. 

Post-mortem Csesarean Operation. — The Cesarean section may also 
be required in cases in which death has occurred during pregnancy 
or labor. This was the indication for which it was first employed, 
and it has constantly been performed when a pregnant woman has 
died at an advanced period of utero-gestation. There is no doubt 
that a prompt extraction of the child under these circumstances has 
frequently been the means of saving its life, but by no means so often 
as is generally supposed. Thus Schwartz 2 showed that out of 107 
cases not one living child was extracted. Villeneuve, 3 however, re- 
ports several successful cases, in 4 of which the operation was per- 
formed immediately after the mother's death, in 5 others at periods 
varying from ten minutes to half an hour. 

Want of Success in Post-mortem Operation. — The reason that the 
want of success has been so great, is doubtless the delay that must 
necessarily occur before the operation is resorted to; for, inde- 
pendently of the fact that the practitioner is seldom at hand at the 
moment of death, the very time necessary to assure ourselves that 
life is actually extinct will generally be sufficient to cause the death 
of the foetus. Considering the intimate relations between the mother 
and child, we can scarcely expect vitality to remain in the latter 
more than a quarter, or at the outside, half an hour, after it has 
ceased in the former. The recorded instances in which a living child 
were extracted ten, twelve, and even forty hours after death, were 
most probably cases in which the mother fell into a prolonged trance 
or swoon, during the continuance of which the child must have been 
removed. A few authentic cases, however, are known in which 
there can be no reasonable doubt that the operation was performed 
successfully several hours after the mother was actually dead. An 
often -quoted and interesting example is that of the Princess of 
Schwartzenburgh, who perished one evening in a fire at Paris, and 
from whose body a living infant is said to have been removed on the 
morning of the following day ; the authenticity of this case, however, 
is open to grave doubt. 

[} This was done twice in the case of Mrs. Reybold, of Philadelphia, after she 
had twice been delivered by craniotomy under Dr. Meigs, who declined destroying 
any more children for her. — Ed.] 

2 Monat. f. Geburt, suppl. vol., 1861, p. 121. 

3 Operat. Csesar. Apres la Mort, Paris. 1862. 



504 OBSTETRIC OPERATIONS. 

Since, then, there is a chance, however slight, of saving the child's 
life, we are bound to perform the operation, even when so much time 
has elapsed as to render the chances of success extremely small. It 
might be considered almost superfluous to iDsist on the necessity of 
assuring ourselves of the mother's death before commencing the neces- 
sary incisions ; but, unfortunately, numerous instances are known in 
which mistakes in diagnosis have been made, and in which the first 
steps of the operation have shown that the mother was still alive. 
The operation should, therefore, always be performed with the same 
care and caution as if the mother were living. If death have 
occurred during labor, some have advised version as a preferable 
alternative. This can only be resorted to, with any hope of success, 
if the passages be in a condition to admit of delivery with rapidity ; 
otherwise the delay required for dilatation, even when forcibly 
accomplished, and the drawing of the child through the pelvis, will 
be almost necessarily fatal. The only argument in favor of version 
is, that it is less painful to the friends ; and, if they manifest a decided 
objection to the Cesarean section, there can be no reason why an 
attempt to save the child in this way should not be made. 

Causes of Death after Csesarean Section. — The causes of death after 
the Csesarean section may, speaking generally, be classed under four 
principal heads ; hemorrhage, peritonitis and metritis, shock, and 
septicaemia. [And exhaustion from long delay. — Ed.] These are 
pretty much the same as those following ovariotomy, and the resem- 
blance between the two operations is so great that modern experience 
as to the best mode of performing ovariotomy, as well as regards the 
after treatment, may be taken as a guide in the management of cases 
of Csesarean section. 

Hemorrhage is Frequent, although Seldom Fatal. — Hemorrhage to 
an alarming extent is a frequent complication, although seldom the 
cause of death. Thus out of 88 operations, the particulars of which 
have been carefully noted, severe hemorrhage occurred in 14, 6 of 
which terminated successfully, and in 4 only could the fatal result be 
ascribed to the loss of blood. In 1 of these the source of the hemor- 
rhage is not mentioned, in another it came from the wound in the 
abdominal wall, and in the other 2 from the uterine incision being 
made directly over the placenta. In neither of the 2 latter was the 
loss of blood immediately fatal ; for it was checked by uterine con- 
traction, and only recurred after many hours had elapsed. The 
divided uterine sinuses, and the open mouths of the vessels at the 
placental site, are the most common sources of hemorrhage. 

Means of avoiding the Risk. — Much may be done to diminish the 
risk of bleeding, but even with every precaution, it must be a source 
of danger. Hemorrhage from the abdominal wall may be best 
prevented by making the incision as nearly as possible in the line 
of the linea alba, so as not to Avound the epigastric arteries, and by 
tying anjr bleeding vessels as we proceed. The principal loss of 
blood will be met with in dividing the uterus; and this will be 
greatest when the incision is near or over the placental site, where 
the largest vessels are met with. We are recommended to ascertain 



CESAREAN SECTION. 505 

the position of the placenta by auscultation, and thus, if possible, to 
avoid opening the uterus near its insertion. But even if we admit 
the placental souffle to be a guide to its situation, if the placenta be 
attached to the anterior walls of the uterus, a knowledge of its posi- 
tion would not always enable us to avoid opening the uterus in its 
immediate vicinity. We must, in the event of its lying under the 
incision, rather hope to control the hemorrhage by removing it at 
once from its attachments, and rapidly emptying the uterus. When 
the child has been removed there may be a large escape of blood; 
but this will generally be stopped by the contraction of the uterus, 
in the same manner as after natural labor. Should contraction not 
take place, the uterus may be firmly grasped for the purpose of 
exciting it. This plan is advocated by Winckel, who had a large 
experience in the operation; and by using free compression in this 
way, and making a point of not closing the wound until the uterus 
is firmly contracted, he has never met with any inconvenience from 
hemorrhage. If bleeding continue, styptic applications may be used, 
as in a case reported by Hicks, who was obliged to swab out the 
uterine cavity with a solution of perchloride of iron. 

Peritonitis and Metritis are frequent Causes of Death. — Among the 
most frequent causes of death are peritonitis and metritis. Kayser 
attributes the fatal result to them in 77 out of 123 unsuccessful cases. 

The mere division of the peritoneum will not account for the fre- 
quency of this complication, since its occurrence is considerably more 
frequent than after ovariotomy, in which the injury to the peritoneum 
is quite as great, and indeed greater, if we take into account the 
adhesions which have to be divided or torn in that operation. 

The division of the uterus must be regarded as one source of this 
danger. Dr. West lays great stress on its unfavorable condition 
after delivery for reparative action. He believes that the process of 
involution or fatty degeneration which commences in the muscular 
fibres previous to delivery, renders them peculiarly unfitted to cica- 
trize ; and he points out that, on post-mortem examination, the edges. 
of the incision have been found dry, of unhealthy color, gaping, and 
showing no tendency to heal. On this account Hicks and others 
have operated ten days or more before the full period of labor, in 
the hope that the risk from this source might be avoided. It is by 
no means certain, however, that the change in the uterine fibres is 
the cause of the wound not healing, and involution will commence 
at once when the uterus is emptied, even if the full period of preg- 
nancy have not arrived. As a point of ethics, moreover, it is question- 
able if we are justified in anticipating the date of so dangerous an 
operation, even by a few weeks, unless the benefit to be derived is 
very decided indeed. 

Escape of Lochia and other Fluids into the Peritoneal Cavity. — One 
important cause of peritonitis is the escape of the lochia through the 
uterine incision into the cavity of the peritoneum, which there de 
compose and act as an unfailing source of irritation. This may be 
prevented, to a great extent, by seeing that the os uteri is patulous, 
so as to afford a channel for the escape of discharges, and by closing 
33 



506 OBSTETRIC OPERATIONS. 

the uterine wound by sutures. In addition there is the danger 
arising from blood and liquor amnii escaping into the peritoneum, 
and subsequently decomposing. There is little evidence that "la 
toilette du peritoine," on which ovariotomists now lay so much 
stress, has ever been particularly attended to in Cesarean operations. 

The Unhealthy Condition of the Patient is the Chief Source of Danger. 
— The chief predisposing cause of these inflammations, however, must 
be looked for in the condition of the patient, just as asthenic inflam- 
mation in ovariotomy is most frequently met with in those whose 
general health is broken down by the long continuance of the disease. 
We are fully justified, therefore, in assuming that peritonitis and 
metritis will be more likely to occur after the Cesarean section when 
that operation has been unnecessarily delayed, and when the patient 
is exhaused by a protracted labor. In proof of this we find that, in 
the large proportion of the cases above mentioned, peritonitis oc- 
curred when the operation was performed under unfavorable con- 
ditions. 

Septicemia. — The sources of septicaemia are abundantly evident, 
not the least, probably, being absorption by the open vessels in the 
uterine incision. 

Nervous Shock. — The last great danger is general shock to the ner- 
vous system. In Kayser's 123 cases, 30 of the deaths are referred 
to this cause. In the large majority of these the patient was pro- 
foundly exhausted before the operation was begun. It is in predis- 
posing to these nervous complications, that we should, d priori, expect 
that vacillation and delay would be most hurtful ; and in operating 
when the patient's strength is still unimpaired, we afford her the best 
chance of bearing the inevitable shock of an operation of such mag- 
nitude. 

Secondary Dangers. — In addition a few cases have been lost from 
accidental complications, which are liable to occur after any serious 
operation, and which do not necessarily depend on the nature of the 
procedure. 

Danger to Child from Portions of its Body being caught by the Con- 
tracting Uterus. — There is only one source of danger, special to the 
child, which is worthy of attention. As the infant is being removed 
from the cavity of the uterus, the muscular parietes sometimes con- 
tract with great rapidity and force, so as to seize and retain some 
part of its body. [A rapid delivery by the feet, will usually prevent 
this, but a pair of forceps should be at hand for the emergency. — Ed.] 
This occurred in 2 of Dr. Kadford's cases, and in 1 of them it is 
stated that " the child was vigorously alive when first taken hold of, 
but, from the length of time occupied in extracting the head, it be- 
came so enfeebled as to show only slight signs of life," and subse- 
quently all attempts at resuscitation failed. I have myself seen the 
head caught in this way, and so forcibly retained that a second in- 
cision was required to release it. In Dr. Kadford's cases the placenta 
happened to be immediately under the incision, and he attributes the 
inordinate and rapid contraction of the uterus to its premature sepa- 
ration. It is difficult to believe that this was more than a coinci- 



CESAREAN SECTION. 507 

cleace, because the contraction does not take place until the greater 
part of the child's body has been withdrawn, and because numerous 
cases are recorded in which the uterus was opened directly over the 
placenta, or in which, it was lying loose and detached, in none of 
which this accident occurred. The true explanation may, I think, 
be found in the varying irritability of the uterus in different cases. 

Irrespective of the risk of portions of the child being caught and 
detained, rapid contraction is a distinct advantage, since the danger 
of hemorrhage is thereby much diminished. Serious consequences 
may be best avoided by removing, when practicable, the head and 
shoulders of the child first, or by employing both hands in extrac- 
tion, one being placed near the head, the other seizing the feet. 
Either of these methods is preferable to the common practice of lay- 
ing hold of the part that may chance to lie most conveniently near 
the line of incision. If this point were properly attended to, al- 
though the detention of the lower extremities might occasionally 
occur, the life of the child would not be imperilled. 

The preparation of the patient for the operation should seriously oc- 
cupy the attention of the practitioner, and this is the more essential, 
since almost all patients requiring the Cesarean section are in a 
wretchedly debilitated condition. [This is the case in England, where 
osteomalacia prevails, but it is exceptional in most cases in our own 
land, in the early period of labor. — Ed.]. If the patient be not seen 
until she is actually in labor, of course this is out of the question. 
But this will rarely be the case, since the deformed condition of the 
patient must generally have attracted attention. Every possible 
means should be taken, therefore, when practicable, to improve the 
general health by abundance of simple and nourishing diet, plenty 
| of fresh air, and suitable tonics (amongst which preparations of iron 
I should occupy a prominent place), while the state of the secretions, 
1 the bowels, skin, and kidneys, should be specially attended to. 
I Whenever it is possible a large, airy apartment should be selected 
for the operation, which should never be done in a hospital, if other 
arrangements be practicable. These details may seem trivial and 
unnecessary ; but to insure success in so hazardous an under- 
taking, no care can be considered superfluous, and probably the 
want of attention to such points has had much to do with increasing 
the mortality. 

Question of Time to he Selected for the Operation. — The question 

arises whether we should operate before labor has commenced. By 

selecting our own time, as some have advised, we certainly have the 

advantage of operating under the most favorable conditions, instead 

of possibly hurriedly. There are, however, numerous advantages in 

I waiting until spontaneous uterine action has commenced, which 

I seem to me to more than counterbalance the advantages of choosing 

I our own time. Prominent among these is the partial opening of the 

; os uteri, so as to afford a channel for the escape of the lochia, and 

I the certainty of active contraction of the uterus, to arrest hemor- 

( rhage. Barnes recommends that premature labor should be first in- 

\ duced, and then the operation performed. This seems to me to 



508 OBSTETRIC OPERATIONS. ■ 

introduce a needless element of complexity ; and besides, in cases of 
great deformity, it is by no means always easy to reach the cervix 
with the view of bringing on labor. All needful arrangements 
should be made, so as to avoid hurry and excitement when the 
operation is commenced, and we may then wait patiently until labor 
has fairly set in. 

The Administration of Anaesthetics. — The operation itself is simple. 
The patient should be placed on a table, in a good light, and with 
the temperature of the room raised to about 65 °. 1 Chloroform has 
so frequently been followed by severe vomiting, that it is probably 
better not to administer it. For the same reason Mr. Spencer Wells. 
has long given up using it in ovariotomy, and finds that chloro- 
methyl answers admirably. In one or two cases local anaesthesia 
has been used, by means of two spray producers acting simulta- 
neously; and this plan, if the patient have sufficient fortitude to 
dispense with general anaesthesia, has the further advantage of 
stimulating the uterus to powerful contraction. 

Description of the Operation. — The incision should be made as much 
as possible in the line of the linea alba, so as to avoid wounding the 
epigastric arteries. On account of the deformity, the configuration 
of the abdomen is often much altered, and some have advised that 
the incision should be made oblique or transverse, and on the most 
prominent part of the abdomen. The risk of hemorrhage being thus 
much increased, the practice is not to be recommended. The incision, 
commencing a little above the umbilicus, is carried down for about 
three inches below it. The skin and muscular fibres are carefully 
divided, layer by layer, until the shining surface of the peritoneum 
is reached, and any bleeding vessels should be secured as we proceed. 
A small opening is now made in the peritoneum, which should be 
laid open along the whole length of the incision, upon two fingers of 
the left hand introduced as a guide. Before incising the uterus an 
assistant should carefully support it in a proper position, and push 
it forward by the hands placed on either side of the incision, so as to 
bring its surface into apposition with the external wound, and pre- 
vent the escape of the intestines. If we have reason to believe that 
the placenta is situated anteriorly, we may incise the uterus on one 
or other side; otherwise the line of incision should be as nearly as 
possible central. The substance of the uterus is next divided until 
the membranes are reached, which are punctured, and divided in the 
same way as the peritoneum. The uterine incision should be of the 
same length as that in the abdomen, and it should not be made too 
near the fundus; for not only is that part more vascular than the 
body of the uterus, but wounds in that situation are more apt to 
gape, and do not cicatrize so favorably. After the uterus is opened, 
Dr. Winckel recommends that the fingers of an assistant should be 
placed in the two terminal angles of the wound, so that the ends of 
the incision may be hooked up, and brought into close apposition 
with the abdominal opening. By this means he prevents not only 

[' The temperature usually recommended in this country is 75° to 80°. — Ei>«] 



CESAREAN SECTION. 509 

the escape of blood and liquor amnii into the cavity of the perito- 
neum, but also the protrusion of the abdominal viscera. 

Removal of the Child. — The child should now be carefully removed, 
the head and shoulders being taken out (if possible) at first; the 
placenta and membranes are afterwards extracted. Should the pla- 
centa be unfortunately found immediately under the incision, a con- 
siderable loss of blood is likely to take place, which can only be 
checked by removing it from its attachments, and concluding the 
operation as rapidly as possible. 

Importance of securing Uterine Contraction. — As soon as the child 
and the secundines have been extracted, the sooner the uterus con- 
tracts the better. It will usually do so of itself, but should it remain 
lax and flabby, it should be pressed and stimulated by the hand. 
"We are specially warned against handling the uterus by Eamsbotham 
and others; but there seems no valid reason why we should not 
restrain hemorrhage in this way, as after a natural labor. The 
intervention of the abdominal parietes, in their lax condition after 
delivery, can make very little difference between the two cases. 

Closure of the Uterine and Abdominal Wounds? — The advisability 
of closing the uterine wound by sutures is a mooted point. The 
balance of evidence is certainly in favor of this practice, as tending 
to prevent the escape of the lochia into the peritoneal cavity. Inter- 
rupted sutures of silver wire or carbolized gut 2 may be used, and cut 
short ; or, as successfully practised by Spencer Wells, a continuous 
silk suture may be applied, one end being passed through the os into 
the vagina, by which it is subsequently withdrawn. Before closing 
the uterine wound one or two fingers should be passed through the 
cervix, to insure its being patulous. A free escape of the lochia in 
this direction is of great consequence, and Winckel even advises the 
placing of a strip of lint, soaked in oil, in the os, so as to keep up a 
free exit for the discharge. 

A point of great importance, and not sufficiently insisted on, is 
the advisability of not closing the abdominal wound until we are 
thoroughly satisfied that hemorrhage is completely stopped, since 
any escape of blood into the peritoneum would very materially lessen 
the chances of recovery. In a successful case reported by Dr. New- 
man, 3 the wound was not closed for nearly an hour. Before doing 
so all blood and discharges should be carefully removed from the 
peritoneal cavity, by clean soft sponges dipped in warm water. The 
abdominal wound should be closed from above downwards, by harelip 
pins, wire or silk sutures, which should be inserted at a distance of 
an inch from each other, and passed entirely through the abdominal 
walls and the peritoneum, at some little distance from the edges of 

\} Sutures, mostly of silver, have been used in fifteen operations out of one hundred 
and one, in the United States. We regard their use as invaluable, where the wound 
gapes from uterine inertia. — Ed.] 

[ 2 Carbolized catgut has been used in the United States but once, and then failed. 
Even when treble-knotted, the suture is apt to become untied. The experience of 
the last ten years in Europe has caused it to be almost universally abandoned. — Ed.] 

3 Obst. Trans., vol. viii. 



510 OBSTETRIC OPERATIONS. 

the incision, so as to bring the two surfaces of the peritoneum into 
contact. By this means we insure the closure of the peritoneal 
cavity, the opposed surfaces adhering with great rapidity. The sur- 
face of the wound is then covered with pads of folded lint, kept in 
position by long strips of adhesive plaster, and the whole covered 
with a soft flannel belt. 

Subsequent Management. — Into the subsequent treatment it is un- 
necessary to enter at any length, since it must be regulated by general 
principles, each symptom being met as it arises. It has been cus- 
tomary to administer opiates freely after the operation ; but they 
seem to have a tendency to produce sickness and vomiting, and ought 
not to be exhibited unless pain or peritonitis indicate that they are 
required. In fact, the treatment should in no way differ from that 
usual after ovariotomy, and the principles that should guide us will 
be best shown by the following quotation from Mr. Spencer Wells's 
description of that operation : " The principles of after-treatment 
are — to obtain extreme quiet, comfortable "warmth, and perfectly 
clean linen to the patient; to relieve pain by warm applications to 
the abdomen, and by opiate enemas; to give stimulants when they 
are called for by failing pulse or other signs of exhaustion; to relieve 
sickness by ice, or iced drinks; and to allow plain, simple, but 
nourishing food. The catheter must be used every six or eight 
hours, until the patient can move without pain. The sutures are re- 
moved on the third day, unless tympanitic distension of the stomach 
or intestines endanger re-opening of the wound. In such circum- 
stances they may be left for some days longer. The superficial 
sutures may remain until union seems quite firm." 

Substitutes for the Csesarean Section; Symphyseotomy . — Bearing in 
mind the great mortality attending the Cesarean section, it is not 
surprising that obstetricians should have anxiously considered the 
possibility of devising a substitute, which should afford the mother 
a better chance of recovery. The first proposal of the kind was one 
from which great results were at first anticipated. In 1768 Sigault, 
then a student of medicine in Paris, suggested symphyseotomy , which 
consists in the division of the symphysis pubis, with the view of 
allowing the pubic bones to separate sufficiently to admit of the 
passage of the child. Although at first strongly opposed, it was sub- 
sequently ardently advocated by many obstetricians, and was often 
performed on the Continent, and in a few cases in this country. 

The Operation is Admitted to be Useless. — It is generally admitted 
that it is quite impossible to make this a substitute for the C cesarean 
section, since the utmost gain which even a wide separation of the 
symphysis pubis would give would be altogether insufficient to admit 
of the passage of even a mutilated foetus. Dr. Churchill concludes 
that, even if were possible to separate it to the extent of four inches, 
we should only have an increase of from four lines to half an inch in 
the antero-posterior diameter, in which the obstruction is generally 
most marked. In the lesser degrees of deformity this might possibly 
be sufficient to allow the foetus to pass ; but the risk of the operation 



CESAREAN SECTION. 511 

itself, and the subsequent ill effects, altogether contra-indicate it in 
cases of this description. 

Laparo-Elytrotomy. — A far more promising operation is one which 
was originally suggested by Jdrg and Eitgen, in 1820, under the 
name of Gastro-Elytrotomy, but which, in the then defective state of 
abdominal surgery, scarcely received attention, and has not even 
been alluded to in any of our standard obstetric works. It has re- 
cently been reconsidered by Professor Thomas, of New York, 1 who 
suggests for it the name of Laparo-Elytrotomy, and it has now been 
performed five times in America. In two out of these cases the 
mother was in articulo mortis, but the remaining three mothers re- 
covered ; and, out of ten, five children were born alive. This is a 
remarkable result, and, at the least, entitles this operation to the 
most earnest attention of the profession. Should future cases show 
anything like the same success it will be the duty of accoucheurs to 
adopt this procedure instead of the almost inevitably fatal Cesarean 
section. 2 

Object of the Operation and its Advantages. — In this operation it is 
proposed to divide the vagina at its juncture with the cervix, this 
being reached by an incision extending from the symphysis pubis to 
the anterior superior spine of the ilium. The loosely-attached peri- 
toneum is then raised up, and the child removed through the os uteri 
by turning, and extracted through the opening in the abdomen. It 
must be at once apparent that the chief dangers of the Cesarean 
section are obviated ; for the peritoneal cavity is not opened (and, 
therefore the risk of peritonitis is much lessened), there is no escape 
of blood into the peritoneum, and the uterus itself is not incised. The 
operation, as described and performed by Thomas, is as follows : — 

1st. An incision is made extending from the symphysis pubis to 
the anterior superior spine of the ilium, dividing the thickness of the 
abdominal walls until the peritoneum is reached.- 

2d. The peritoneum is lifted up by means of the fingers, or by 
metal retractors, so as to admit of the juncture of the vagina and 
uterus being reached. So far the operation is precisely that which 
is practised by surgeons for the ligature of the iliac arteries, and 
offers no particular difficulties. 

3d. The vagina is made to protrude in the wound by means of a 
metal sound, introduced through the vulva, and is divided to a suffi- 
cient extent. 

4th. This will allow the cervix to be reached, and it is drawn into 
the iliac fossa by a blunt hook passed into it, while the fundus uteri 
is depressed by an assistant in an opposite direction. If the os uteri 
be sufficiently open (and if possible it should have been previously 
dilated with caoutchouc bags), the hand is passed into the uterus, and 
the child removed by turning. 

1 Laparo-Elvtrotomy, a substitute for the Cesarean Section: read before the New 
York Academy of Medicine, March 6, 1878. 

2 [A very careful canvass of the State of Louisiana, carried on for some years, 
shows 18 Csesarean operations with 14 women saved. — Ed.] 



512 OBSTETRIC OPERATIONS. 

In the American cases no special difficulty was met with in the 
performance of the operation, although in some of them the perito- 
neum was thickened and united to the neighboring parts by antece- 
dent inflammation. It is worthy of notice that in none of them was 
there any hemorrhage of consequence, although the iarge vascular 
supply to the vagina naturally renders that one of the most serious 
risks which we have to apprehend. 

No one who has seen much of ovariotomy could reasonably hold 
that there is anything in this procedure incompatible with success. 
Whether subsequent experience will justify the hopes that Dr. 
Thomas holds out, remains to be seen. Of course, all that can now 
be said of it is, that the operation is theoretically sufficiently simple, 
and that it offers a possible way of removing the child, without some 
of the gravest risks of the Csesarean section. Should hemorrhage 
occur, it would probably be quite within control, either by ligatures, 
or, as Thomas suggests, by passing a metallic speculum either through 
the abdominal wound or the vagina, and applying through it the 
actual cautery or the perchloride of iron. No difficulty need be 
anticipated in retracting the peritoneum to a sufficient extent, for in 
pregnancy that membrane is unusually ample, and much more loose 
in its attachments than in the non-pregnant state. 

[This operation, devised by Eitgen and Physick, and put into suc- 
cessful practice by Thomas and Skene, may possibly prove much 
less fatal than gastro-hysterotomy has in England, but we have 
grave doubts as to its adaptation to the rostrate pelvis of malacos- 
teon, which must materially interfere with delivery through the vagi- 
nal incision. — Ed.] 

[The Cesarean operation in our own country, with all its disad- 
vantages in a newly settled and sparsely inhabited land, has been so 
much more successful than in Great Britain, that we are inclined to 
regard it with much less dread of consequences than is done by 
English obstetricians. We are very apt in the United States to be 
influenced by the medical experiences of the Old World, and to cal- 
culate risks in operations by their collected statistics, when a careful 
collation at home, would show very different results. In no one 
operation perhaps, is there a more marked difference, than is to be 
found in the records of gastro-hysterotomy in England and America. 
This is due to several causes, which are greatly in our favor. 1. We 
have the advantages of a dry climate. 2. Osteomalacia, the adult 
bone-softening, so prevalent among child-bearing women of the Old 
World, and so fruitful a cause of pelvic deformity, does not prevail 
here, and has in no instance in America been the cause of difficulty, 
which has made the Cesarean section a necessity. 3. To the exist- 
ence of this disease we attribute much of the want of success in 
Great Britain. 4. We have no beer-drinking peasant women to 
operate upon, than whom worse subjects for surgery can scarcely be 
found. 5. We do not operate upon a woman with the feeling, that 
in all human probability she is much more likely to die than recover, 
and on this account, make her case almost hopeless by long delay, or 
by various fruitless and exhausting expedients to avoid the resort to 



CESAREAN SECTION. 513 

what has been denominated "the forlorn hope" We have in many 
instances failed through delay; but a comparison made between 
timely English and American operations is very largely in our favor. 1 
By means of a long-continued research, and an extensive correspond- 
ence, we have collected the records of 108 American Cesarean cases, 
101 of them being in the United States. Fifty one of the 108 women 
were saved alive, and 45 out of the 101 ; the proportionate mortality 
in the second instance, being increased by the fact, that 38 of the 101 
cases had never been published, such operations having been fatal 
in the proportion of two to one saved. Published cases, as a rule, 
show much the most favorable side of the question, our own giving 
a mortality of only 36 per cent, against one of 68 per cent., in those ob- 
tained by direct correspondence. We believe that our statistics more 
fully represent the truth with regard to gastro-hysterotomy in our 
country than those of any other land yet published; although after 
nine years 1 search we feel that the work is still imperfect. 

What most concerns us, is to determine the true clanger of the 
operation in the United States, when performed with due regard to 
time and condition. This we can approach in a measure by noting 
the result in 24 cases where the section was made early in labor; 
there were 18 women and 21 children saved. 

Seventeen operations performed npon eight women resulted favor- 
ably in fourteen instances ; one died from the third operation and two 
from the second. 

We are inclined to believe, that if timely performed, and with 
due skill and care, the Cassarean operation in our country is not as 
dangerous as craniotomy in pelves having a conjugate diameter of 
2J inches or less. This was the opinion of the late Dr. Parry, 2 and 
our own observations have fully confirmed his views. In this city 
the Cesarean operation has been performed four times with a loss of 
two women, all the children being alive at the last accounts. 

There is no reason why our obstetricians should stand in awe of 
this operation if they are prompt in deciding and acting, so as to 
give both mother and child the best possible prospect of life. It 
should always be remembered, that the danger does not lie so much 
in incising the uterus per se, as in making the incision, when this 
organ has been rendered susceptible to inflammatory action by its 
prolonged efforts at expulsion and by exhaustion on the part of the 
patient. Ovariotomists by their repeated successes, have prepared the 
way for a more hopeful view of gastro-hysterotomy and of laparotomy 
for the purpose of delivery in rupture of the uterus and abdominal 
pregnancy; and there is reason to believe that in time all these 
operations will be performed with an encouraging hope of success. — ■ 
Ed.] 

1 See Harris on Gastro-hysterotomy, Am. Jour. Med. Sei., April, 1878, p. 324. 



514 OBSTETRIC OPERATIONS. 



CHAPTEE VII. 

THE TRANSFUSION OF BLOOD. 

The transfusion of blood in desperate and apparently hopeless 
cases of hemorrhage, offers a possible means of rescuing the patient 
which merits careful consideration. It has again and again attracted 
the attention of the profession, but has never become popularized in 
obstetric practice. The reason of this is not so much the inherent 
defects of the operation itself — for quite a sufficient number of suc- 
cessful cases are recorded to make it certain that it is occasionally a 
most valuable remedy — but the fact that the operation has been con- 
sidered a delicate and difficult one, and that it has been deemed 
necessary to employ complicated and expensive apparatus, which is 
never at hand when a sudden emergency arises. Whatever may be 
the difference of opinion about the value of transfusion, I think it 
must be admitted that it is of the utmost consequence to simplify 
the process in every possible way, and it is above all things neces- 
sary to show that the steps of the operation are such as can be readily 
performed by any ordinarily-qualified practitioner, and that the ap- 
paratus is so simple and portable as to make it easy for any obstetri- 
cian to have it at hand. There are comparatively few who would 
consider it worth while to carry about with them, in ordinary every- 
day work, cumbrous and expensive instruments which may never be 
required in a life-long practice ; and hence it is not unlikely that, in 
many cases in which transfusion might have proved useful, the op- 
portunity of using it has been allowed to slip. Of late years the 
operation has attracted much attention, the method of performing it 
has been greatly simplified, and I think it will be easy to prove that 
all the essential apparatus may be purchased for a few shillings, and 
in so portable a form as to take up little or no room ; so that it 
may be always carried in the obstetric bag ready for any possible 
emergency. 

The history of the operation is of considerable interest. In Villari's 
" Life of Savonarola " it is said to have been employed in the case of 
Pope Innocent VIII., in the year 1492, but I am not aware on what 
authority the statement is made. The first serious proposals for its 
performance do not seem to have been made until the latter half of 
the seventeenth century. It was first actually performed in France, 
by Denis, of Montpellier, although Lower, of Oxford, had previously 
made experiments on animals which satisfied him that it might be 
undertaken with success. In November, 1667, some months after 
Denis's case, he made a public experiment at Arundel House, in 
which twelve ounces of sheep's blood were injected into the veins ot 
a healthy man, who is stated to have been very well after the opera- 



THE TRANSFUSION OF BLOOD. 515 

tion, which must, therefore, have proved successful. These u early 
simultaneous cases gave rise to a controversy as to priority of inven- 
tion, which was long carried on with much bitterness. 

The idea of resorting to transfusion after severe hemorrhage does 
not seem to have been then entertained. It was recommended as a 
means of treatment in various diseased states, or with the extrava- 
gant hope of imparting new life and vigor to the old and decrepit. 
The blood of the lower animals only was used ; and, under these cir- 
cumstances, it is not surprising that the operation, although practised 
on several occasions, was never established as it might have been had 
its indications been better understood. 

From that time it fell almost entirely into oblivion, although ex- 
periments and suggestions as to its applicability were occasionally 
made, especially by Dr. Harwood, Professor of Anatomy at Cam- 
bridge, who published a thesis on the subject in the year 1785. He, 
however, never carried his suggestions into practice, and, like his pre- 
decessors, only proposed to employ blood taken from the lower 
animals. In the year 1824 Dr. Blundell published his well-known 
work, entitled "Kesearches, Physiological and Pathological," which 
detailed a large number of experiments ; and to that distinguished 
physician belongs the undoubted merit of having brought the subject 
prominently before the profession, and of pointing out the cases in 
which the operation might be performed with hopes of success. 
Since the publication of this work, transfusion has been regarded as 
a legitimate operation under special circumstances ; but, although it 
has frequently been performed with success, and in spite of many in- 
teresting monographs on the subject, it has never become so estab- 
lished, as a general resource in suitable cases, as its advantages would 
seem to warrant. Within the last few years more attention has been 
paid to the subject, and the writings of Panum, Martin, and de Belina, 
abroad, and of Higginson, McDonnell Hicks, and Aveling at home, 
amongst many others, have thrown much light on many points con- 
nected with the operation, and it is to be hoped that the committee 
appointed by the Obstetrical Society, in their forthcoming report, 
may still more increase our knowledge. 

Nature and Object of the Operation. — Transfusion is practically only 
employed in cases of profuse hemorrhage connected with labor, al- 
though it has been suggested as possibly of value in certain other 
puerperal conditions, such as eclampsia, or puerperal fever. Theo- 
retically it may be expected to be useful in such diseases ; but, inas- 
much as little or nothing is known of its practical effects in these 
diseased states, it is only possible here to discuss its use in cases of 
excessive hemorrhage. Its action is probably twofold. 1st, the 
actual restitution of blood which has been lost. 2d, the supply of a 
sufficient quantity of blood to stimulate the heart to contraction, and 
thus to enable the circulation to be carried on until fresh blood is 
formed. The influence of transfusion as a means of restoring lost 
blood must be trivial, since the quantity required to produce an effect 
is generally very small indeed, and never sufficient to counter- 
balance that which has been lost. Its stimulant action is no doubt 



516 OBSTETRIC OPERATIONS. 

of far more importance ; and if the operation be performed before 
the vital energies are entirely exhausted, the effect is often most 
marked. 

Use of Blood taken from the Lower Animals. — In the earliest opera- 
tions the blood used was always that of the lower animals, generally 
of the sheep. Dr. Blundell believed that such blood could not be 
employed with success. Eecent cases, such as those published by 
Keene, who used lamb's blood in 12 cases, 1 have conclusively proved 
this idea to be erroneous. Brown-Sequard has shown that Blundell's 
experiments with animal blood failed, partly because he used too 
large a quantity and injected too quickly, and partly because he used 
blood too rich in carbonic acid and too poor in oxygen. He has 
shown that the success of the operation must depend to a great ex- 
tent on these points, and that blood, containing sufficient carbonic 
acid to be black, proves directly poisonous, unless it is injected in 
very small quantity, and with great slowness. Although, then, it 
is certain that the blood of some of the lower animals, especially of 
those in which the corpuscles are of less size than in man, as in sheep, 
can be employed with safety, still the operation, of late years, has 
been almost always performed with human blood alone, and, for 
many obvious reasons, is always likely to be so. 

Difficulties from Coagulation of Fibrine — The great practical diffi- 
culty in transfusion has always been the coagulation of the blood 
very shortly after it has been removed from the body. When fresh 
drawn blood is exposed to the atmosphere, the fibrine commences to 
solidify rapidly, generally in from three to four minutes, sometimes 
much sooner. It is obvious that the moment fibrination has com- 
menced the blood is, ijjso facto, unfitted for transfusion, not' only be- 
cause it can be no longer passed readily through the injecting appa- 
ratus, but because of the great danger of propelling small masses of 
fibrine into the circulation, and thus causing embolism. Hence, if no 
attempt be made to prevent this difficulty, it is essential, no matter 
what apparatus is used, to hurry on the operation so as to inject be- 
fore fibrination has begun. This is a fatal objection, for there is no 
operation in the whole range of surgery in which calmness and de- 
liberation are so essential, the more so as the surroundings of the 
patient in these unfortunate cases are such as to tax the presence 
of mind and coolness of the practitioner and his assistants to the 
utmost. 

Methods of Obviating Coagulation. — All the recent improvements 
have had for their object the avoidance of coagulation, and practi- 
cally this has been effected in one of three ways. 1st, hj immediate 
transfusion from arm to arm, without allowing the blood to be ex- 
posed to the atmosphere, according to the methods proposed by 
Aveling and Koussel. [Direct tubular transfusion from arm to arm, 
is pictured in Heister's Surgery, London, 1768, p. 336. — Ed.] 2d, by 
adding to the blood certain chemical reagents which have the pro- 
perty of preventing coagulation. 3d, removal of the fibrine entirely, 

1 London Med. Record, Dec. 31, 1873. 



THE TRANSFUSION OF BLOOD. 517 

by promoting its coagulation and straining the blood, so that the 
liquor sanguinis and blood corpuscles alone are injected. 

Inasmuch as the success of the operation altogether depends on 
the method adopted, it will be well, before going further, to consider 
briefly the advantages and disadvantages of each of these plans. 

Immediate Transfusion. — 1. The method of immediate transfusion 
has been brought prominently before the profession by Dr. Aveling, 
who has invented an ingenious apparatus for performing it. The 
apparatus consists essentially of a miniature Higginson's syringe, 
without valves, and with a small silver canula at either end. One 
canula is inserted into the vein of the person supplying blood, the 
other into a vein of the patient, and by a peculiar manipulation of 
the syringe, subsequently to be described, the blood is carried from 
one vein into the other. It must be admitted that, if there were no 
practical difficulties, this instrument would be admirable, and it is 
therefore not surprising that it should have met with so much favor 
from the profession. I cannot but think, however, that the opera- 
tion is not so simple as it at first sight appears, and that therefore it 
wants one of the essential elements required in any procedure for 
performing transfusion. One of my objections is, that it is by no 
means easy to work the apparatus without considerable practice. 
Of this I have satisfied myself by asking members of my class to 
work it after reading the printed directions, and finding that they 
are not always able to do so at once. Of course it may be said that 
it is easy to acquire the necessary manipulative skill ; but, when the 
necessity for transfusion arises, there is no time left for practising 
with the instrument, and it is essential that an apparatus, to be uni- 
versally applicable, should be capable of being used immediately, 
and without previous experience. Other objections are the necessity 
of several assistants, the uncertainty of there being a sufficient circu- 
lation of blood in the veins of the donor to afford a constant supply, 
and the possibility of the whole apparatus being disturbed by rest- 
lessness or jactitation on the part of the patient. For these reasons, 
it seems to me that this plan of immediate transfusion is not so 
simple, nor so generally applicable, as defibrination. Still, it is im- 
possible not to recognize its merits, and it is certainly well worthy 
of further study and investigation. 

Another method of immediate transfusion is that recommended 
by Eoussel, 1 whose apparatus has recently attracted considerable 
attention. It possesses many undoubted advantages, and is, beyond 
doubt, a valuable addition to our means of performing the opera- 
tion. It has, however, the great disadvantage of being costly and 
complicated, and hence I do not believe that it is likely to come into 
general use. 

Addition of Chemical Agents to Prevent Coagulation. — 2. The second 
plan for obviating the bad effects of clotting is the addition of some 
substance to the blood which shall prevent coagulation. It is well 
known that several salts have this propert}^, and the experiments 

1 Obstetrical Transactions, vol. xviii. 



518 OBSTETRIC OPERATIONS. 

made in the case of cholera patients prove that solutions of some of 
them may be injected into the venous system without injury. This 
method has been specially advocated by Dr. Braxton Hicks, who 
uses a solution of three ounces of fresh phosphate of soda in a pint 
of water, about six ounces of which are added to the quantity of 
blood to be injected. He has narrated 4 cases 1 in which this plan 
was adopted successfully, so far as the prevention of coagulation was 
concerned. It certainly enables the operation to be performed with 
deliberation and care, but it is somewhat complicated; and it may 
often happen that the necessary chemicals are not at hand. A further 
objection is the bulk of fluid which must be injected, and there is 
reason to believe that this has, in some cases, seriously embarrassed 
the heart's action, and interfered with the success of the operation. 
In many of the successful cases of transfusion the amount of blood 
injected has been very small, not more than two ounces. Dr. 
Eichardson proposes to prevent coagulation by the addition of 
liquor ammonise to the blood, in the proportion of two minims, 
diluted with twenty minims of water, to each ounce of blood. 

Defibrination of the Blood. — 3. The last method, and the one which, 
on the whole, I believe to be the simplest and most effectual, is defi- 
brination. It has been chiefly practised in this country by Dr. 
McDonnell, of Dublin, who has published several very interesting 
cases in which he employed it, and abroad by Martin, of Berlin ; de 
Belina, of Paris [and James G. Allen, of Philadelphia. — Ed.]. The 
process of removing the fibrine is simple in the extreme, and occu- 
pies a few minutes only. Another advantage is that the blood to 
be transfused may be prepared quietly in an adjoining apartment, so 
that the operation may be performed with the greatest calmness and 
deliberation, and the donor is spared the excitement and distress 
which the sight of the apparently moribund patient is apt to cause, 
and which, as Dr. Hicks has truly pointed out, may interfere with 
the free flow of blood. The researches of Panum, Brown-Sequard, 
and others, have proved that the blood corpuscles are the true vivi- 
fying element, and that defibrinated blood acts as well, in every 
respect, as that containing fibrine. It has been proved that the 
fibrine is reproduced within a short time, 2 and the whole tendency 
of modern research is to regard it, not as an essential element of the 
blood, but as an excrementitious product, resulting from the degra- 
dation of tissue, which may, therefore, be advantageously removed. 
Another advantage derived from defibrination is, that the corpuscles 
are freely exposed to the atmosphere, oxygen is taken up, and car- 
bonic acid given off, and the dangers which Brown-Sequard has 
shown to arise from the use of blood containing too much carbonic 
acid are thereby avoided. There can be, therefore, no physiological 
objection to the removal of the fibrine, which, moreover, takes away 
all practical difficulty from the operation. The straining to which 
the defibrinated blood is subjected entirely prevents the possibility 

1 Guy's Hosp. Reports, vol. xiv. 

2 Panum, Virchow's Arch., vol. xxvii 



THE TRANSFUSION OF BLOOD. 519 

of even the most minute particle of fibrine being contained in the 
injected fluid; the risk from embolism is, therefore, less than in any 
of the other processes already referred to. My own experience of 
this plan is limited to 3 cases, but in 2 it answered so well that I can 
conceive no reasonable objection to it. I should be inclined to say 
that transfusion, thus performed, is amongst the simplest of surgical 
operations — an opinion which the experience of McDonnell and 
others fully confirms. 

Statistical Results. — The number of cases of transfusion are perhaps 
not sufficient to admit of completely reliable conclusions. It is cer- 
tain, however, that transfusion has often been the means of rescuing 
the patient when apparently at the point of death, and after all other 
means of treatment had failed. Professor Martin records 57 cases, 
in 43 of which transfusion was completely successful, and in 7 tem- 
porarily so; while in the remaining 7 no reaction took place. Dr. 
Higginson, of Liverpool, has had 15 cases, 10 of which were success- 
ful. Figures such as these are encouraging, and they are sufficient 
to prove that the operation is one which at least offers a fair hope of 
success, and which no obstetrician would be justified in neglecting, 
when the patient is sinking from the exhaustion of profuse hemor- 
rhage. It is to be hoped also that further experience may prove it 
to be of value in other cases, in which its use has been suggested, 
but not, as yet, put to the test of experiment. 

Possible Dangers of the Operation. — The possible risks of the opera- 
tion would seem to be the danger of injecting minute particles of 
fibrine which form emboli, or bubbles of air, or of overwhelming the 
action of the heart by injecting too rapidly, or in too great quantity. 
These may be, to a great extent, prevented by careful attention to 
the proper performance of the operation, and it does not clearly 
appear, from the recorded cases, they have ever proved fatal. We 
must also bear in mind that transfusion is seldom or ever likely to 
be attempted until the patient is in a state which would otherwise 
almost certainly preclude the hope of recovery, and in which, there- 
fore, much more hazardous proceedings would be fully justified. 

Cases Suitable for Transfusion. — The cases suitable for transfusion 
are those in which the patient is reduced to an extreme state of 
exhaustion from hemorrhage during or after labor or miscarriage, 
whether by the repeated losses of placenta prsevia, or the more 
sudden and profuse flooding of post-partum hemorrhage. The opera- 
tion will not be contemplated until other and simpler means have 
been tried and failed, or until the symptoms indicate that life is on 
the verge of extinction. If the patient should be deadly pale and 
cold, with no pulse at the wrist, or one that is scarcely perceptible ; 
if she be unable to swallow, or vomits incessantly; if she lie in an 
unconscious state; if jactitation, or convulsions, or repeated fainting 
should occur; if the respiration be laborious, or very rapid and 
sighing; if the pupil do not act under the influence of light; it is 
evident that she is in a condition of extreme danger, and it is, under 
such circumstances, that transfusion, performed sufficiently soon, 
offers a fair prospect of success. It does not necessarily follow be- 



520 OBSTETRIC OPERATIONS. 

cause one or other of these symptoms is present, that there is no 
chance of recovery under ordinary treatment, and indeed it is within 
the experience of all, that patients have rallied under apparently the 
most hopeless conditions. But when several of them occur together, 
the prospect of recovery is much diminished, and transfusion would 
then be fully justified, especially as there is no reason to think that 
a fatal result has ever been directly traced to its employment. In- 
deed, like most other obstetric operations, it is more likely to be 
postponed until too late to be of service, than to be emploj^ed too 
early; and in some of the cases reported as unsuccessful, it was not 
performed until respiration had ceased, and death had actually taken 
place. It has been sometimes said that transfusion can never be 
employed if the uterus be not firmly contracted, so as to prevent the 
injected blood again escaping through the uterine sinuses. The cases 
in which this is likely to occur are few; and if one were met w r ith, 
the escape of blood could be prevented by the injection into the 
uterus of the perchloride of iron. 

Description of the Operation. — In describing the operation I shall 
limit myself to an account of Aveling's method of immediate trans- 
fusion, and to that of injecting defibrinated blood. I consider myself 
justified in omitting any account of the numerous apparatuses which 
have been invented for the purpose of injecting pure blood, since I 
believe the practical difficulties are too great ever to render this form 
of operation serviceable. The great objection to most of the instru- 
ments used is their cost and complexity : and as long as any special 
apparatus is considered essential, the full benefits to be derived from 
transfusion are not likely to be realized. The necessity for employ- 
ing it arises suddenly ; it may be in a locality in which it is impossi- 
ble to procure a special instrument; and it would be well if it were 
understood that transfusion may be safely and effectually performed 
by the simplest means. In many of the successful cases an ordinary 
syringe was used ; in one, in the absence of other instruments, a 
child's toy syringe was employed. I have nryself performed it with 
a simple syringe purchased at the nearest chemist's shop, when a 
special transfusion apparatus failed to act satisfactorily. 

Method of performing Immediate Transfusion. — In immediate trans- 
fusion (Fig. 180), the donor is seated close to the patient, and the 
veins in the arms of each having been opened, the silver canula at 
either end of the instrument is introduced into them (a b). The tube 
between the bulb and the patient is now pinched (d), so as to form a 
vacuum, and the bulb becomes filled with blood from the donor. 
The finger is now removed so as to compress the distal tube (d'), 
and the bulb being compressed (c), its contents are injected into the 
patient's vein. The bulb is calculated to hold about two drachms, 
so that the amount injected can be estimated by the number of times 
it is emptied. The risk of injecting air is prevented by filling the 
syringe with Avater, which is injected before the blood. 

Injection of Defibrinated Blood. — For injecting defibrinated blood 
various contrivances have been used. McDonnell's instrument is a 
simple cylinder with a nozzle attached, from which the blood is pro- 



THE TRANSFUSION OF BLOOD 



521 



pelled by gravitation. When the propulsive power is insufficient, 
increased pressure is applied by breathing forcibly into the open end 
of the receiver. De Belina's instrument is on the same principle, 
only atmospheric pressure is supplied by a contrivance similar to 



Fig. 180. 




i D 

Method of Transfusion by Aveling's Apparatus. 

Kichardson's spray-producer, attached to one end. The idea is simple, 
but there is some doubt of a gravitation instrument being sufficiently 
powerful, and it certainly' failed in my hands. I have had valves 
applied to Aveling's instrument, so that it works by compression of 
the bulb, like an ordinary Higginson's syringe. This, with a single 
silver canula at one end, for introduction into the vein, forms a per- 
fect and inexpensive transfusion apparatus, taking up scarcely any 
space. If it be not at hand, any small syringe, with a tolerably fine 
nozzle, may be used. 

Mode of Preparing the Blood. — The first step of the operation is 
defibrination of the blood, which should, if possible, be prepared in 
an apartment adjoining the patient's. The blood should be taken 
from the arm of a strong and healthy man. The quality cannot be 
unimportant, and, in some recorded cases, the failure of the operation, 
has been attributed to the fact of the donor having been a weakly 
female. The supply from a woman might also prove insufficient ; 
and, although it has been shown that blood from two or more per- 
sons may be used with safety, yet such a change necessarily causes 
delay, and should, if possible, be avoided. A vein having been 
opened, eight or ten ounces of blood are withdrawn, and received 
into some perfectly clean vessel, such as a dessert finger-glass. As it 
flows it should be briskly agitated with a clean silver fork, or a glass 
rod, and, very shortly, strings of fibrine begin to form. It is now 
strained through a piece of fine muslin, previously dipped in hot 
water, into a second vessel which is floating in water at a tempera- 
ture of about 105°. By this straining the fibrine and air-bubbles 
resulting from the agitation are removed, and, if there be no exces- 
sive hurry, it might be well to repeat the straining a second time. It 
the vessel be kept floating in warm water, the blood is prevented 
34 



522 OBSTETRIC OPERATIONS. 

from getting cool, and we can now proceed to prepare the arm of the 
patient for injection. 

Mode of Exposing the Veins selected for Transfusion. — This is the 
most delicate and difficult part of the operation, since the veins are 
generally collapsed and empty, and by no means easy to find. The 
best way of exposing them is that practised by McDonnell, who 
pinches up a fold of the skin at the bend of the elbow, and transfixes 
it with a fine tenotomy knife or scalpel, so making a gaping wound 
in the integument, at the bottom of which they are seen lying. A 
probe should now be passed underneath the vein selected for opening, 
so as to avoid the chance of its being lost at any subsequent stage of 
the operation. This is a point of some importance, and from the neglect 
of this precaution I have been obliged to open another vein than that 
originally fixed on. A small portion of the vein being raised with 
the forceps, a nick is made into it for the passage of the canula. 

Injection of the Blood. — The prepared blood is now brought to the 
bedside, and, the apparatus having been previously filled with blood 
to avoid the risk of injecting any bubbles of air, the canula is in- 
serted into the opening made in the vein, and transfusion commenced. 
It should be constantly borne in mind that this part of the operation 
should be conducted with the greatest caution, the blood introduced 
very slowly, and the effect on the patient carefully watched. The 
injection may be proceeded with until some perceptible effect is pro- 
duced, which will generally be a return of the pulsation, first at the 
heart, and subsequently at the wrist, an increase in the temperature 
of the body, greater depth and frequency of the respirations, and a 
general appearance of returning animation about the countenance. 
Sometimes the arms have been thrown about, or spasmodic twitch - 
ings of the face have taken place. The quantity of blood required 
to produce these effects varies greatly, but in the majority of cases 
has been very small. Occasionally 2 ounces have proved sufficient, 
and the average may be taken as ranging between 4 and 6 : although 
in a few cases between 10 and 20 have been used. The practical 
rule is to proceed very slowly with the injection until some per- 
ceptible result is observed. Should embarrassed or frequent respira- 
tion supervene, Ave may suspect that we have been injecting either 
too great a quantity of blood, or with too much force and rapidity, 
and the operation should at once be suspended, and not resumed until 
the suspicious symptoms have passed away. It may happen that the 
effects of the transfusion have been highly satisfactory, but that in 
the course of time there is evidence of returning syncope. This may 
possibly be prevented by the administration of stimulants ; but if 
these fail there is no reason why a fresh supply of blood should not 
again be injected, but this should be done before the effects of the 
first transfusion have entirely passed away. 

Secondary Effects of Transfusion. — The subsequent effects in suc- 
cessful cases of transfusion merit careful study. In some few cases 
death is said to have happened within a few weeks, with symptoms 
resembling pyemia. Too little is known on this point, however, to 
justify any positive conclusions with regard to it. 

[For an account of the intra- venous injection of milk, see Appen- 
dix.— Ed.] 



PART V. 

THE PUERPERAL STATE 



CHAPTER I. 

THE PUERPEKAL STATE AND ITS MANAGEMENT. 

Importance of Studying the Puerperal State. — The key to the man- 
agement of women after labor, and to the proper understanding of 
the many important diseases which may then occur, is to be found in 
a study of the phenomena following delivery, and of the changes 
going on in the mother's system during the puerperal period. ISFo 
doubt natural labor is a physiological and healthy function, and 
during recovery from its effects disease should not occur. It must 
not be forgotten, however, that none of our patients are under phy- 
siologically healthy conditions. The surroundings of the lying-in 
woman, the effects of civilization, of errors of diet, of defective clean- 
liness, of exposure to contagion, and of a hundred other conditions, 
which it is impossible to appreciate, have most important influences 
on the results of childbirth. Hence it follows that labor, even under 
the most favorable conditions, is attended with considerable risk. 

The Mortality of Childbirth. — It is not easy to say with accuracy 
what is the precise mortality accompanying childbirth in ordinary 
domestic practice, since the returns derived from the reports of the 
Registrar-General, or from private sources, are manifestly open to 
serious error. The nearest approach to a reliable estimate is that 
made by Dr. Matthews Duncan, 1 who calculates from figures derived 
from various sources, that not fewer than 1 out of every 120 women, 
delivered at or near the fall time, dies within four weeks of child- 
birth. This indicates a mortality far above that which has been 
generally believed to accompany child-bearing under favorable cir- 
cumstances. It, however, closely approximates to a similar estimate 
made by McClintock, 2 who calculates the mortality in England and 
Wales as 1 in 126 ; and in the upper and middle classes alone, where 
the conditions may naturally be supposed to be more favorable, as 1 
in 146. In these calculations there are some obvious sources of 
error, since they include deaths from all causes within four weeks of 
delivery, some of which must have been independent of the puerperal 
state. 

1 "The Mortality of Childbed," Edin. Med. Journ., Nov. 1869. 

2 Dublin Quarterly Journ., Aug. 1869. 



524 THE PUERPERAL STATE. 

But it is not the deaths alone which should be considered. All 
practitioners know how large a number of their patients suffer from 
morbid states which may be directly traced to the effects of child- 
bearing. It is impossible to arrive at any statistical conclusion on 
this point, but it must have a very sensible and important influence 
on the health of child-bearing women. 

Alterations in the Blood after Delivery. — The state of the blood 
during pregnancy, already referred to, has an important bearing on 
the puerperal state. There is hyperinosis, which is largely increased 
by the changes going on immediately after the birth of the child ; for 
then the large supply of blood, which has been going to the uterus, 
is suddenly stopped, and the system must also get rid of a quantity 
of effete matter thrown into the circulation, in consequence of the 
degenerative changes occurring in the muscular fibres of the uterus. 
Hence all the depurative channels, by which this can be eliminated, are 
called on to act with great activity. If, in addition, the peculiar con- 
dition of the generative tract be borne in mind — viz., the large open 
vessels on its inner surface — the partially bared inner surface of the 
uterus, and the channels for absorption existing in consequence of 
slight lacerations in the cervix or vagina — it is not a matter of sur- 
prise that septic diseases should be so common. 

Condition after Delivery. — It will be well to consider successively 
the various changes going on after delivery, and then we shall be 
in a better position for studying the rational management of the 
puerperal state. 

Nervous Shock. — Some degree of nervous shock or exhaustion is 
observable after most labors. In many cases it is entirely absent ; 
in others it is well marked. Its amount is in proportion to the 
severity of the labor, and the susceptibility of the patient ; and it is, 
therefore, most likely to be excessive in women who have suffered 
greatly from pain, who have undergone much muscular exertion, or 
who have been weakened from undue loss of blood. It is evidenced 
by a feeling of exhaustion and fatigue, and not uncommonly there 
is some shivering, which soon passes off, and is generally followed 
by refreshing sleep. The extreme nervous susceptibility continues 
for a considerable time after delivery, and indicates the necessity of 
keeping the lying-in patient as free from all sources of excitement as 
possible. 

Fall of the Pulse. — Immediately after deliver}?- the pulse falls, and 
the importance of this, as indicating a favorable state of the patient, 
has already been alluded to. The condition of the pulse "has been 
carefully studied by Blot, 1 avIio has shown that this diminution, 
Avhich he believes to be connected with an increased tension in the 
arteries, due to the sudden arrest of the uterine circulation, continues, 
in a large proportion of cases, for a considerable number of days 
after delivery ; and, as a matter of clinical import, as long as it does, 
the patient may be considered to be in a favorable state. In many 
instances the slowness of the pulse is remarkable, often sinking to 

1 Arch. G6n. de M6d., 1864. 



THE PUERPERAL STATE AND ITS MANAGEMENT. 525 

50 or even 40 beats per minute. Any increase above the normal 
rate, especially if at all continuous, should always be carefully noted, 
and looked on with suspicion. In connection with this subject, 
however, it must be remembered that in puerperal women the most 
trivial circumstances may cause a sudden rise of the pulse. This 
must be familiar to every practical obstetrician, who has constant 
opportunities of observing this effect after any transient excitement 
or fatigue. In lying-in hospitals it has generally been observed that 
the occurrence of any particularly bad case will send up the pulse of 
all the other patients who may have heard of it. 

Temperature in the Puerperal State. — The temperature in the lying- 
in state affords much valuable information. Daring, and for a short 
time after labor, there is a slight elevation. It soon falls to, or even 
somewhat below, the normal level. Squire found that the fall oc- 
curred within twenty-four hours, sometimes within twelve hours, 
after the termination of labor. 1 For a few days there is often a 
slight increase of temperature, which is probably caused by the rapid 
oxidation of tissue in connection with the involution of the uterus. 
In about forty-eight hours there is a rise connected with the estab- 
lishment of lactation, amounting to one or two degrees over the 
normal level; but this again subsides as soon as the milk is freely 
secreted. Crede" has also shown 2 that rapid, but transient, rises of 
temperature may occur at any period, connected with trivial causes, 
such as constipation, errors of diet, or mental disturbances. But, if 
there be any rise of temperature which is at all continuous, especially 
to over 100° Fahr., and associated with rapidity of the pulse, there 
is reason to fear the existence of some complication. 

The Secretions and Excretions. — The various secretions and excre- 
tions are carried on with increased activity after labor. The skin 
especially acts freely, the patient often sweating profusely. There 
is also an abundant secretion of urine, but not uncommonly a diffi- 
culty of voiding it, either on aocount of temporary paralysis of the 
neck of the bladder, resulting from the pressure to which it has been 
subjected, or from swelling and occlusion of the urethra. For the 
same reason the rectum is sluggish for a time, and constipation is 
not infrequent. The appetite is generally indifferent, and the patient 
is often thirsty. 

Secretion of Milk. — Generally in about forty-eight hours the secre- 
tion of milk becomes established, and this is occasionally accompanied 
by a certain amount of constitutional irritation. The breasts often 
become turgid, hot, and painful. There may, or may not, be some 
general disturbance, quickening of pulse, elevation of temperature, 
possibly slight shivering, and a general sense of oppression, Avhich 
are quickly relieved as the milk is formed, and the breasts emptied 
by suckling. Squire says that the most constant phenomenon con- 
nected with the temperature is a slight elevation as the milk is 
secreted, rapidly falling when lactation is established. Barker noted 

i (< Puerperal Temperatures," Obstetrical Transactions, vol. ix. 
2 Monat. f. Geburt, Dec. 1868. 



526 THE PUERPERAL STATE. 

elevation, either of temperature or pulse, in only 4 out of 52 cases 
which were carefully watched. There can be little doubt that the 
importance of the so-called "milk fever" has been immensely ex- 
aggerated, and its existence, as a normal accompaniment of the 
puerperal state, is more than doubtful. It is certain, however, that, 
in a small minority of cases, there is an appreciable amount of dis- 
turbance about the time that the milk is formed. Many modern 
writers, such as Winckel, Griinewaldt, and d'Espine, entirely deny 
the connection of this disturbance with lactation, and refer it to a 
slight and transient septicaemia. Grraily Hewitt remarks that it is 
most commonly met with when the patient is kept low and on defi- 
cient diet after delivery, especially when the system is below par 
from hemorrhage, or any other cause. This observation will, no 
doubt, account for the comparative rarity of febrile disturbance in 
connection with lactation in these days, in which the starving of 
puerperal patients is not considered necessary. It is certain that 
anything deserving the name of milk fever is now altogether excep- 
tional, and such feverishness as exists is generally quite transient. 
It is also a fact, that it is most apt to occur in delicate and weakly 
women, especially in those who do not, or are unable to, nurse. 
There does not, however, seem to be any sufficient reason for refer- 
ring it, even when tolerably well marked, to septicaemia. The relief 
which attends the emptying of the breasts seems sufficient to prove 
its connection with lactation, and the discomfort which is necessarily 
associated with the swollen and turgid mammae, is, of itself, quite 
sufficient to explain it. 

Contraction of the Uterus after Delivery. — Immediately after de- 
livery the uterus contracts firmly, and can be felt at the lower part 
of the abdomen as a hard, firm mass, about the size of a cricket ball. 
After a time it again relaxes somewhat, and alternate relaxations and 
contractions go on, at intervals, for a considerable time after the 
expulsion of the placenta. The more complete and permanent the 
contraction, the greater the safety and comfort of the patient ; for 
when the organ remains in a state of partial relaxation, coagula are 
apt to be retained in its cavity, while, for the same reason, air enters 
more readily into it. Hence decomposition is favored, and the chances 
of septic absorption are much increased ; while, even when this does 
not occur, the muscular fibres are excited to contract, and severe 
after-pains are produced. 

Subsequent Diminution in the Size of the Uterus. — After the first 
few days the diminution in the size of the uterus progresses with 
great rapidity. By about the sixth day it is so much lessened as to 
project not more than 1 J or 2 inches above the pelvic brim, while by 
the eleventh day it is no longer to be made out by abdominal palpa- 
tion. Its increased size is, however, still apparent per vaginam, and, 
should occasion arise for making an internal examination, the mass 
of the lower segment of the uterus, with its flabby and patulous 
cervix, can be felt for some weeks after delivery. This may some- 
times be of practical value in cases in which it is necessary to ascer- 
tain the fact of recent delivery, and, under these circumstances, as 



THE PUERPERAL STATE AXD ITS MANAGEMENT. 527 

pointed out by Simpson, the uterine sound would also enable us to 
prove that the cavity of the uterus is considerably elongated. Indeed 
the normal condition of the uterus and cervix is not regained until 
six weeks or two months after labor. These observations are corro- 
borated by investigations on the weight of the organ at different 
periods after labor. Thus Heschl 1 has shown that the uterus, imme- 
diately after delivery, weighs about 22 to 24 ozs. ; within a week, it 
weighs 19 to 21 ozs.; and at the end of the second week, 10 to 11 
ozs. only. At the end of the third week, it weighs 5 to 7 ozs. ; but 
it is not until the end of the second month that it reaches its normal 
weight. Hence it appears that the most rapid diminution occurs 
during the second week after delivery. 

Fatty Transformation of the Muscular Fibres. — The mode in which 
this diminution in size is effected is by the transformation of the 
muscular fibres into molecular fat, which is absorbed into the mater- 
nal vascular system, which, therefore, becomes loaded with a large 
amount of effete material. Heschl has shown that the entire mass 
of the enlarged uterine muscles are removed, and replaced by newly- 
formed fibres, which commence to be developed about the fourth 
week after delivery, the change being complete about the end of the 
second month. Generally speaking, involution goes on without inter- 
ruption. It is, however, apt to be interfered with by a variety of 
causes, such as premature exertion, intercurrent disease, and, very 
probably, by neglect of lactation. Hence the uterus often remains 
large and bulky, and the foundation for many subsequent uterine 
ailments is laid. 

Changes in the Uterine Vessels. — Williams has drawn attention to 
changes occurring in the vessels of the uterus, some of which seem 
to be permanent, and may, should further observations corroborate 
his investigations, prove of value in enabling us to ascertain whether 
a uterus is nulliparous or the reverse ; a question which may be of 
medico-legal importance. After pregnancy he found all the vessels 
enlarged in calibre. The coats of the arteries are thickened and 
hypertrophied, and this he has observed even in the uteri of aged 
women who have not borne children for may years. The venous 
sinuses, especially at the placental site, have their walls greatly 
thickened and convoluted, and contain in their centre a small clot of 
blood (Fig. 181). This thickening attains its greatest dimensions in 
the third month after gestation, but traces of it may be detected as 
late as ten or twelve weeks after labor. 

Changes in the Uterine Mucous Membrane. — The changes going on 
in the lining membrane of the uterus immediately after delivery are 
of great importance in leading to a knowledge of the puerperal state, 
and have already been discussed when describing the decidua (p. 94). 
Its cavity is covered with a reddish-gray film, formed of blood and 
fibrine. The open mouths of the uterine sinuses are still visible, 
more especially over the site of the placenta, and thrombi may be 

1 Researches on the Conduct of the Human Uterus after Delivery. 



528 



THE PUERPERAL STATE. 



seen projecting from them. The placental site can be distinctly made 
out, in the form of an irregularly oval patch, where the lining mem- 
brane is thicker than elsewhere. 




Section of a Uterine Sinus from the Placental Site nine weeks after Delivery. (After William-;.) 

Contraction of the Vagina, etc. — The vagina soon contracts, and, by 
the time the puerperal month is over, it has returned to its normal 
dimensions, but after child-bearing it always remains more lax, and 
less rugous, than in nullipara}. The vulva, at first very lax and 
much distended, soon regains its former state. The abdominal pari- 
etes remain loose and flabby for a considerable time, and the white 
streaks, produced by the distension of the cutis, very generally be- 
come permanent. In some women, especially when proper support 
by bandaging has not been given, the abdomen remains permanently 
loose and pendulous. 

The Lochial Discharge. — From the time of delivery, up to about 
three weeks afterwards, a discharge escapes from the interior of the 
nterus, known as the lochia. At first this consists almost entirely of 
pure blood, mixed with a variable amount of coagula. If efficient 
uterine contraction have not been secured after the expulsion of the 
placenta, coagula of considerable size are frequently expelled with 
the lochia for one or two days after delivery. In three or four days 
the distinctly bloody character of the lochia is altered. They have 
a reddish watery appearance, and are known as the lochia rubra or 
cruenta. According to the researches of ATertheimer, 1 they are at 



Yiivhow's Arch., 1861. 



THE PUERPERAL STATE AND ITS MANAGEMENT. 529 

this time composed chiefly of blood corpuscles, mixed with epithelium 
scales, mucous corpuscles, and the debris of the decidua. The change 
in the appearance of the discharge progresses gradually, and about 
the seventh or eighth day it has no longer a red color, but is a pale 
greenish fluid, Avith a peculiar sickening and disagreeable odor, and 
is familiarly described as the " green waters." It now contains a 
l smaller quantity of blood corpuscles, which lessen in amount from 
day to day, but a considerable number of pus corpuscles, which re- 
main the principal constituent of the discharge until it ceases. Besides 
I these, epithelial scales, fatty granules, and crystals of cholesterine, 
are observed. Occasionally a small infusorium, which has been 
named the "trichomena vaginalis," has been detected; but it is into 
of constant occurrence. 

Variation in its Amount and Duration. — The amount of the lochia 
varies much, and in some women it is habitually more abundant 
than in others. Under ordinary circumstances it is very scanty after 
the first fortnight, but occasionally it continues somewhat abundant 
for a month or more, without any bad results. It is apt again to 
become of a red color, and to increase in quantity, in consequence 
of airy slight excitement or disturbance. If this red discharge con- 
! tinue for any undue length of time, there is reason to suspect some 
abnormality, and it may not unfrequently be traced to slight lacera- 
tions about the cervix, which have not healed properly. This result 
may also follow premature exertion, interfering with the proper in- 
volution of the uterus ; and the patient should certainly not be 
alloAved to move about as long as much colored discharge is going on. 

Occasional Fetor of the Discharge. — Occasionally the lochia have 
an intense^ fetid odor. This must always give rise to some anxiety, 
since it often indicates the retention and putrefaction of coagula, and 
involves the risk of septic absorption. It is not very rare, however, 
to observe a most disagreeable odor persist in the lochia without any 
bad results. The fetor always deserves careful attention, and an 
endeavor should be made to obviate it by directing the nurse to 
syringe out the vagina freely night and morning with Condy's fluid 
and water; while, if it be associated with quickened pulse and 
elevated temperature, other measures, to be subsequently described, 
will be necessary. 

The after-pains, which many child-bearing women dread even 
more than the labor-pains, are irregular contractions, occurring for 
a varying time after delivery, and resulting from the efforts of the 
uterus to expel coagula which have formed in its interior. If, there- 
fore, special care be taken to secure complete and permanent con- 
traction after labor, they rarely occur, or to a very slight extent. 
Their dependence on uterine inertia is evidenced by the common 
observation that they are seldom met with in primiparaB, in whom 
uterine contraction may be supposed to be more efficient, and are 
most frequent in women who have borne many children. They are 
a preventible complication, and one which need not give rise to any 
anxiety; they are, indeed, rather salutary than the reverse, for if 
1 coagula be retained in utero, the sooner they are expelled the better. 



530 THE PUERPERAL STATE. 

The after-pains generally begin a few hours after delivery, and con- 
tinue in bad cases, for three or four days, but seldom longer. [These 
pains are frequently increased immediately upon giving the child 
the breast, the drawing of the milk acting sympathetically upon the 
uterus and causing much annoyance. — Ed.] When at their height 
they are often relieved by the expulsion of the coagula. They may 
be readily distinguished from pains due to more serious causes, by 
feeling the enlarged uterus harden under their influence, by the 
uterus not being tender on pressure, and by the absence of any con- 
stitutional symptoms. 

Management of Women after Delivery. — The management of women 
after child-birth has varied much at different times, according to 
fashion or theory. The dread of inflammation long influenced the 
professional mind, and caused the adoption of a strictly antiphlo- 
gistic diet, which led to a tardy convalescence. The recognition of 
the essentially physiological character of labor has resulted in more 
sound views, with manifest advantage to our patients. The main 
facts to bear in mind with regard to the puerperal woman are, her 
nervous susceptibility, which necessitates quiet and absence of all 
excitement ; the importance of favoring involution by prolonged 
rest ; and the risk of septicaemia, which calls for perfect cleanliness 
and attention to hygienic precautions. 

The Administration of Opiates is generally Unadvisahle. — As soon 
as we are satisfied that the uterus is perfectly contracted, and that 
all risk of hemorrhage is over, the patient should be left to sleep. 
Many practitioners administer an opiate; but, as a matter of routine, 
this is certainly not good practice, since it checks the contractions of 
the uterus, and often produces unpleasant effects. Still, if the labor 
have been long and tedious, and the patient be much exhausted, 15 
or 20 drops of Battley's solution may be administered with advantage. 

Attention to the State of the Pulse, Bladder, and Uterus. — Within a 
few hours the patient should be seen, and at the first visit particular 
attention should be paid to the state of the pulse, the uterus, and 
the bladder. The pulse during the whole period of convalescence 
should be carefully watched, and, if it be at all elevated, the tem- 
perature should at once be taken. If the pulse and temperature 
remain normal, we may be satisfied that things are going on well ; 
but if the one be quickened and the other elevated, some disturbance 
or complication may be apprehended. The abdomen should be felt 
to see that the uterus is not unduly distended, and that there is no 
tenderness. After the first day or two this is no longer necessary. 

Treatment of Retention of Urine. — Sometimes the patient cannot 
at first void the urine, and the application of a hot sponge over the 
pubis may enable her to do so. If the retention of urine be due to 
temporary paralysis of the bladder, three or four 20-minim doses of 
the liquid extract of ergot, at intervals of half an hour, may prove 
successful. Many hours should not be allowed to elapse without re- 
lieving the patient by the catheter, since prolonged retention is only 
likely to make matters worse. Subsequently, it may be necessary 
to empty the bladder night and morning, until the patient regain her 



THE PUERPERAL STATE A 2s D ITS MANAGEMENT. 531 

power over it, or until the swelling of the urethra subsides, and this 
will generally be the case in a few days. Occasionally the bladder 
becomes largely distended, and is relieved to some degree by drib- 
bling of urine from the urethra, Such a state of things may deceive 
the patient and nurse, and may produce serious consequences by 
causing cystitis. Attention to the condition of the abdomen will 
prevent the practitioner from being deceived, for in addition to some 
constitutional disturbance, a large, tender, and fluctuating swelling 
will be found in the hypogastric region, distinct from the uterus, 
which it displaces to one or other side. The catheter will at once 
prove that this is produced by distension of the bladder. 

Treatment of Severe After-pains. — If the after-pains be very severe, 
an opiate may be administered, or, if the lochia be not over-abund- 
ant, a linseed-meal poultice, sprinkled with, laudanum, or with the 

■ chloroform and belladonna liniment, may be applied. If proper care 
have been taken to induce uterine contraction, they will seldom be 
sufficiently severe to require treatment. In America, quinine in 

; doses of 10 grains twice daily, has been strongly recommended, espe- 
cially when opiates fail, and when the pains are neuralgic in character, 
and I have found this remedy answer extremely well. 

Diet and Regimen. — The diet of the puerperal patient claims care- 
ful attention, the more so as old prejudices in this respect are as yet 
far from exploded, and as it is by no means rare to find mothers and 
nurses who still cling tenaciously to the idea that it is essential to 
prescribe a low regimen for many days after labor. The erroneous- 
ness of this plan is now so thoroughly recognized, that it is hardly 
necessary to argue the point. There is, however, a tendency in some 
to err in the opposite direction, which leads them to insist on the 
patient's consuming solid food too soon after delivery, before she has 
regained her appetite, thereby producing nausea and intestinal de- 
rangement, Our best guide in this matter is the feelings of the pa- 
tient herself. If, as is often the case, she be disinclined to eat, there 
is no reason why she should be urged to do so. A good cup of beef- 
tea, some bread and milk, or an egg beat up with milk, may gener- 
ally be given with advantage shortly after delivery, and many patients 
are not inclined to take more for the first day or so. If the patient 
be hungry there is no reason why she should not have some more 
solid, but easily digested food, such as white fish, chicken, or sweet- 
bread; and, after a day or two, she may resume her ordinary diet, 
bearing in mind that, being confined to bed, she cannot with advan- 
tage consume the same amount of solid food as when she is up and 
about. Dr. Oldham, in his presidential address to the Obstetrical 
Society, 1 has some apposite remarks on this point, which are worthy 
of quotation. "A puerperal month under the guidance of a monthly 
nurse is easily drawn out, and it is well if a love of the comforts of 
illness and the persuasion of being delicate, which are the infirmities 
of many women, do not induce a feeble life, which long survives 
after the occasion of it is forgotten. I know no reason why, if a 

1 Obstet. Trans, vol. vi. 



532 THE PUERPERAL STATE. 

woman is confined early in the morning, she should not have her 
breakfast of tea and toast at nine, her luncheon of some digestible 
meat at one, her cup of tea at five, her dinner with chicken at seven, 
and her tea again at nine, or the equivalent, according to the varia- 
tion of her habits of living. [With our ideas in the United States, 
we do not think American women would stand this sort of substan- 
tial diet so soon after deliver}^. In fact few in the higher walks of 
life would care to try the experiment, or have the appetite to enjoy 
it — Ed.] Of course, there is the common sense selection of articles 
of food, guarding against excess, and avoiding stimulants. But gruel 
and slops, and all intermediate feeding, are to be avoided." No one 
who has seen both methods adopted can fail to have been struck 
with the more rapid and satisfactory convalescence which takes place 
when the patient's strength is not weakened by an unnecessarily low 
diet. Stimulants, as a rule, are not required ; but, if the patient, 
be weakly and exhausted, or if she be accustomed to their use, 
there can be no reasonable objection to their judicious administra- 
tion. 

Attention to Cleanliness, &c, — Immediately after delivery a warm 
napkin is applied to the vulva, and, after the patient has rested a 
little, the nurse removes the soiled linen from the bed, and washes 
the external genitals. It is impossible to pay too much attention 
during the subsequent progress of the case to the maintenance of 
perfect cleanliness. The linen should be frequently changed, and all 
dirty linen and discharges immediately removed from the apartment. 
The vulva should be washed daily with Condy's fluid and water, and 
the patient will derive great comfort from having the vagina 
syringed gently out once a day with the same solution. The re- 
markable diminution of mortality which has followed such antisep- 
tic precautions in certain Lying-in Hospitals in Germany, well shows 
the importance of these measures. The room should be kept toler- 
ably cool, and fresh air freely admitted. 

Action of the Bowels. — It is customary, on the morning of the 
second or third day, to secure an action of the bowels; and there is 
no better way of doing this than by a large enema of soap and ivater. 
If the patient object to this, and the bowels have not acted, some mild 
aperient may be administered, such as a small dose of castor oil, a 
few grains of colocynth and henbane pill, or the popular French 
aperient, the "Tamar Indien." 

Lactation. — The management of suckling and of the breasts forms 
an important part of the duties of the monthly nurse, which the prac- 
titioner should himself superintend. This will be more conveniently 
discussed under the head of lactation. 

Importance of Prolonged Rest. — The most important part of the 
management of the puerperal state is the securing to the patient pro- 
longed rest in the horizontal position, in order to favor proper invo- 
lution of the uterus. For the first few days she should be kept as 
quiet and still as possible, not receiving the visits of any but her 
nearest relatives, thus avoiding all chance of undue excitement. It 
is customary among the better classes for the patient to remain in 



^ 



MANAGEMENT OF THE INFANT, LACTATION, ETC 



bed for eight or ten days ; but, provided she be doing well, there can 
be no objection to her lying on the outside of the bed, or slipping on 
to a sofa, somewhat sooner. After ten days or a fortnight she may 
be permitted to sit on a chair for a little ; but I am convinced that 
the longer she can be persuaded to retain the recumbent position, 
the more complete and satisfactory will be the progress of involution, 
and she should not be allowed to walk about until the third week, 
about which time she may also be permitted to take a drive. 1 If it 
be borne in mind that it takes from six weeks to two months for the 
uterus to regain its natural size, the reason for prolonged rest will be 
obvious. The judicious practitioner, however, while insisting on this 
point, will take measures, at the same time, not to allow the patient 
to lapse into the habits of an invalid, or to give the necessary rest 
the semblance of disease. 

Subsequent Treatment. — Towards the termination of the puerperal 
month some slight tonic, such as small doses of quinine with phos- 
phoric acid, may be often given with advantage, especially if conva- 
lescence be tardy. Nothing is so beneficial in restoring the patient 
to her usual health as change of air, and in the upper classes a short 
visit to the seaside may generally be recommended, with the certainty 
of much benefit. 



CHAPTEK II. 

STATION, ETC. 

Commencement of Respiration. — Almost immediately after its ex- 
pulsion, a healthy child cries aloud, thereb}^ showing that respiration 
is established, and this may be taken as a signal of its safety. The 
first respiratory movements are excited, partly by reflex action result- 
ing from the contact of the cold external air on the cutaneous nerves, 
and partly by the direct irritation of the medulla oblongata, in conse- 
quence of the circulation through it of blood no longer oxygenated 
in the placenta. 

Apparent Death of the New-born Child. — Not infrequently the child 
is born in an apparently lifeless state. This is especially likely to 
be the case when the second stage of labor has been unduly pro- 
longed, so that the head has been subjected to long-continued pres- 
sure. The uteroplacental circulation is also apt to be injuriously 
interfered with before the birth of the child when a tardy labor has 

[' In Paris, among patients of the higher walks of life, the time for remaining in 
bed is usually twenty-one days, even after very easy labors : the accoucheurs claiming 
that this length of rest is required, if we expect to avoid uterine displacements. — Ed.] 



534 THE PUERPERAL STATE. 

produced tonic contraction of the uterus, and consequent closure of 
the uterine sinuses; or, more rarely, from such causes as the injudi- 
cious administration of ergot, premature separation of the placenta, 
or compression of the umbilical cord. In any of these cases it is 
probable that the arrest of the uteroplacental circulation induces 
attempts at inspiration, which are necessarily fruitless, since air 
cannot reach the lungs, and the foetus may die asphyxiated; the 
existence of the respiratory movement being proved on post-mortem 
examination by the presence in the lungs of liquor amnii, mucus, 
and meconium, and by the extravasation of blood from the rupture 
of their engorged vessels. 

Appearance of the Child in such Cases. — In most cases, when the 
child is born in a state of apparent asphyxia, its face is swollen and 
of a dark livid color. It not infrequently makes one or two feeble 
and gasping efforts at respiration, without any definite cry; on aus- 
cultation the heart may be heard to beat weakly and slowly. Under 
such circumstances there is a fair hope of its recovery. In other 
cases the child, instead of being turgid and livid in the face, is pale, 
with flaccid limbs, and no appreciable cardiac action, then the prog- 
nosis is much more unfavorable. 

Treatment of Apparent Death. — No time should be lost in endeavor- 
ing to excite respiration, and, at first, this must be done by applying 
suitable stimulants to th° cutaneous nerves, in the hope of exciting 
reflex action. The cord should be at once tied, and the child re- 
moved from the mother; for the final uterine contractions have so 
completely arrested the utero-placental circulation, as to render it no 
longer of any value. If the face be yerv livid, a few drops of blood 
may with advantage be allowed to flow from the cord before it is 
tied, with the view of relieving the embarrassed circulation. Yery 
often some slight stimulus, such as one or two sharp slaps on the 
thorax, or rapidly rubbing the body with brand}?- poured into the 
palms of the hands, will suffice to induce respiration. Failing this, 
nothing acts so well as the sudden and instantaneous application of 
heat and cold. For this purpose extremely hot water is placed in 
one basin, and quite cold water in another. Taking the child by 
the shoulders and legs, it should be dipped for a single moment into 
the hot water, and then into the cold; and these alternate applica- 
tions may be repeated once or twice, as occasion requires. The 
effect of this measure is often very marked, and I have frequently 
seen it succeed when prolonged efforts at artificial respiration had 
been made in vain. 

Artificial Respiration. — If these means fail, an endeavor must be 
at once made to carry on respiration artificially. The Sylvester 
method is, on the whole, that which is most easily applied, and, on 
account of the compressibility of the thorax, it is peculiarly suitable 
for infants. The child being laid on its back, with the shoulders 
slightly elevated, the elbows are grasped by the operator, and alter- 
nately raised above the head, and slowly depressed against the sides 
of the thorax, so as to produce the effect of inspiration and expiration. 
If this do not succeed, the Marshall Hall method may be substituted ; 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 535 

and one or more of the plans of exciting reflex action through the 
cutaneous nerves may be alternated with it. 

Insufflation of the Lungs. — Other means of exciting respiration have 
been recommended. One of them, much used abroad, is the artificial 
insufflation of the lungs by means of a flexible catheter guided into 
the glottis. It is not difficult to pass the end of a catheter into the 
glottis, using the little finger as a guide ; and once in position, it may 
be used to blow air gently into the lungs, which is expelled by com- 
pression on the thorax, the insufflation being repeated at short inter- 
vals of about ten seconds. One advantage of this plan is, that it 
allows the liquor aranii and other fluids, which may have been 
drawn into the lungs in the premature efforts at respiration before 
birth, to be sucked up into the catheter, and so removed from the 
lungs. The same effect may be produced, but less perfectly, by 
placing the hand over the nostrils of the child, blowing into its 
mouth, and immediately afterwards compressing the thorax. 1 One 
of these methods should certainly be tried, if all other means have 
failed. Faradization along the course of the phrenic nerves is a 
promising means of inducing respiration, which should be used if 
the proper apparatus can be procured. Encouragement to persevere 
in oar endeavors to resuscitate the child may be derived from the 
numerous authenticated instances of success after the lapse of a 
considerable time, even of an hour or more. As long as the cardiac 
pulsations continue, however feebly, there is no reason to despair. 

Washing and Dressing of the Child. — When the child cries lustily 
from the first, it is customary for the nurse to wash and dress it as 
soon as her immediate attendance on the mother is no longer required. 
i For this purpose it is placed in a bath of warm water, and carefully 
soaped and sponged from head to foot. With the view of facilitating 
the removal of the unctuous material with which it is covered, it is 
usual to anoint it with cold cream or olive-oil, which is washed off 
in the bath. Nurses are apt to use undue roughness in endeavoring 
to remove every particle of the vernix caseosa, small portions of 
which are often firmly adherent. This mistake should be avoided, as 
these particles will soon dry up and become spontaneously detached. 
The cord is generally wrapped in a small piece of charred linen, 
which is supposed to have some slight antiseptic property, and this 
is renewed from day to day until the cord has withered and separated. 
This generally occurs within a week ; and a small pad of soft linen is 
then placed over the umbilicus, and supported by a flannel belly- 
band, placed round the abdomen, which should not be too tight, for 
fear of embarrassing the respiration. By this means the tendency 
to umbilical hernia is prevented. [Many obstetricians have adopted 
the plan in our country of cleaning the child at the first dressing 
without water. Grease is well applied, and the body carefully wiped 

[ ! When this is done the oesophagus must be closed by placing the thumb and 
fingers on opposite sides of the larynx, and pressing it backward, just before blowing 
in the mouth. When this is accomplished so as to fill the lungs, the thorax should 
be pressed, and the inflation repeated. — Ed.] 



536 THE PUERPERAL STATE. 

from head to foot with soft rags, until the skin is cleansed of every- 
thing but a slight oily trace, not sufficient to soil the clothing. This 
makes the skin soft, and the child is in less danger of taking cold 
than when soap and water are used. — Ed.] 

Clothing, etc. — The clothing of the infant varies according to fashion 
and the circumstances of the parents. The important points to bear 
in mind are that it should be warm (since newly-born children are 
extremely susceptible to cold), and at the same time light, and suffi- 
ciently loose to allow free play to the limbs and thorax. All tight 
bandaging and swaddling, such as is so common in some parts of the 
Continent, should be avoided, and the clothes should be fastened by 
strings or by sewing, and no pins used. At the present day it is 
customary not to use caps, so that the head may be kept cool. The 
utmost possible attention should be paid to cleanliness, and the child 
should be regularly bathed in tepid water, at first once daily, and, 
after the first few weeks, both night and morning. After drjdng, 
the flexures of the thighs and arms, and the nates, should be dusted 
with violet powder or Fuller's earth, to prevent chafing of the skin. 
The excrements should be received in napkins wrapped round the 
hips, and great care is required to change the napkins as often as 
they are wet or soiled, otherwise troublesome irritation will arise. 
A neglect of this precaution, and the washing of the napkins with 
coarse soap or soda, are among the principal causes of the eruptions 
and excoriations so common in badly cared for children. When 
washed and dressed the child may be placed in its cradle, and covered 
with soft blankets or an eider-brown quilt. 

Application of the Child to the Breast. — As soon as the mother has 
rested a little, it is advisable to place the child to the breast. This 
is useful to the mother by favoring uterine contraction. Even now 
there is in the breasts a variable quantity of the peculiar fluid known 
as colostrum. This is a viscid yellowish secretion, different in appear- 
ance from the thin bluish milk which is subsequently formed. Ex- 
amined under the microscope it is found to contain some milk 
globules, a number of large granular and small fat corpuscles. It 
has a purgative property, and soon produces, with less irritation 
than any of the laxatives so generally used, a discharge of the meco- 
nium with which the bowels are loaded. Hence the accoucheur 
should prohibit the common practice of administering castor oil, or 
other aperient, within the first few days after birth, although there 
can be no objection to it, in special cases, if the bowels appear to act 
inefficiently and with difficulty. 

Over-frequent Suckling should be Avoided. — For the first few daj^s, 
and until the secretion of milk is thoroughly established, the child 
should be put to the breast at long intervals only. Constant attempts 
at suckling an empty breast lead to nothing but disappointment, both 
to the mother and child, and, by unduly irritating the mammae, some- 
times to positive harm. Therefore, for the first day or two, it is 
sufficient if the child be applied to the breast twice, or at most three 
times, in the twenty -four hours. Nor is it necessary to be apprehen- 
sive, as many mothers naturally are, that the child will suffer from 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 537 

want of food. A few spoonfuls of milk and water being given from 
time to time, the child may generally wait without injury until the 
milk is secreted. This is generally about the third day, when the 
secretion is found to be a whitish fluid, more watery in appearance 
than cow's milk, and showing under the microscope an abundance 
of minute spherical globules, refracting light strongly, which are 
abundant in proportion to the quality of the milk. A certain number 
of granular corpuscles may also be observed shortly after the birth 
of the child, but, after the first month, these should have almost 
altogether disappeared. The reaction of human milk is decidedly 
alkaline, and the taste much sweeter than that of cow's milk. 

Importance of Nursing ivhen Practicable. — The importance to the 
mother of nursing her own child, whenever her health permits, on 
account of the favorable influence of lactation in promoting a proper 
involution of the uterus, has already been insisted on. Unless there 
be some positive contra-indication, such as a marked strumous 
cachexia, an hereditary phthisical tendency, or great general debil- 
ity, it is the duty of the accoucheur to urge the mother to attempt 
lactation, even if it be not carried on more than a month or two. It 
is, however, the fact that in the upper classes of society a large 
number of patients are unable to nurse, even though willing and 
anxious to do so. In some there is hardly any lacteal secretion at 
all, in others there is at first an over-abundance of watery and innu- 
tritious milk, which floods the breasts, and soon dies away altogether. 

[Milk Diet for the Mother. — Many can be enabled to nurse well by 
being largely fed with milk, the allowance gradually increased with 
the age of the child. One of our patients of 86 pounds weight, took 
2 quarts daily, and gained 19 pounds. She had failed on three 
former occasions in a month, but on this one nursed 18 months. — Ed.] 

When the Mother cannot Nurse a Wet Nurse should be Procured. — 
Whenever the mother cannot or will not nurse, the question will 
arise as to the method of bringing up the child. From many causes 
there is an increasing tendency to resort to bottle-feeding, instead of 
procuring the services of a wet nurse, even when the question of 
expense does not come into consideration. No long experience is 
required to prove that hand-feeding is a bad and imperfect substitute 
for nature's mode, and one which the practitioner should discourage 
whenever it lies in his power to do so. 1 It is true that, in many 
cases, bottle-fed children do well ; but there is good reason to believe 
that, even when apparently most successful, the children are not so 
strong in after-life as they would have been had they been brought 
up at the breast. When, in addition, it is borne in mind how much 
of the success of hand feeding depends on intelligent care on the 
part of the nurse, what evils are apt to accrue from injurious selec- 
tion of food, and from ignorance of the commonest laws of dietetics, 
there is abundant reason for urging the substitution of a wet nurse, 
whenever the mother is unable to undertake the suckling of her 

[ l There is no country in which this is more realized than our own, where cholera 
infantum is so prevalent. — Ed.] 
35 



538 THE PUERPERAL STATE. 

child. It must be admitted that good hand-feeding is better than 
bad wet nursing, and the success of the latter hinges on the proper 
selection of a wet nurse. As this falls within the duties of the prac- 
titioner, it will be well to point out the qualities which should be 
sought for in a wet nurse, before proceeding to discuss the mode of 
rearing the child at the breast. 

Selection of a Wet Nurse. — In selecting a wet nurse we should en- 
deavor to choose a strong, healthy woman, who should not be over 
30, or 35 years of age at the outside, since the quality of the milk 
deteriorates in women who are more advanced in life. For a similar 
reason a very young woman of 16 or 17 should be rejected ; It is 
needless to say that care must be taken to ascertain the absence of 
all traces of constitutional disease, especially marks of scrofula, or 
enlarged cervical or inguinal glands, which may possibly be due to 
antecedent syphilitic taint. If the nurse be of good muscular de- 
velopment, healthy-looking, with a clear complexion, and sound 
teeth (indicating a generally good state of health), the color of the 
hair and eyes are of secondary importance. It is commonly stated 
that brunettes make better nurses than blondes, but this is by no 
means necessarily the case ; and, provided all the other points be favor- 
able, fairness of skin and hair need be no bar to the selection of a 
nurse. The breasts should be pear-shaped, rather firm, as indicating 
an abundance of gland-tissue, and with the superficial veins well 
marked. Large, flabby breasts owe much of their size to an undue 
deposit of fat, and are generally unfavorable. The nipple should be 
prominent, not too large, and free from cracks and erosions, which, 
if existing, might lead to subsequent difficulties in nursing. On 
pressing the breast the milk should flow from it easily in a number 
of small jets, and some of it should be preserved for examination. 
It should be of a bluish-white color, and when placed under the 
microscope, the field should be covered with an abundance of milk 
corpuscles, and the large granular corpuscles of the colostrum should 
have entirely disappeared. If the latter be observed in any quantity 
in a woman who has been confined five or six weeks, the inference 
is that the milk is inferior in quality. It is not often that the prac- 
titioner has an opportunity of inquiring into the moral qualities of 
the nurse, although much valuable information might be derived 
from a knowledge of her previous character. An irascible, excit- 
able, or highly nervous woman will certainly make a bad nurse, and 
the most trivial causes might afterwards interfere with the quality 
of her milk. Particular attention should be paid to the nurse's own 
child, since its condition affords the best criterion of the quality of 
her milk. It should be plump, well nourished, and free from all 
blemishes. If it be at all thin and wizened, especially if there be 
any snuffling at the nose, or should any eruption exist affording the 
slightest suspicion of a syphilitic taint, the nurse should be unhesi- 
tatingly rejected. 

Management of Suckling. — The management of suckling is much 
the same whether the child is nursed by the mother or by a wet 
nurse. As soon as the supply of milk is sufficiently established, 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 539 

the child must be put to the breast at short iutervals, at first of about 
two hours, and, in about a month or six weeks, of three hours. From 
the first few days it is a matter of the greatest importance, both 
to the mother and child, to acquire regular habits in this respect. 
If the mother get into the w T ay of allowing the infant to take the 
breast whenever it cries, as a means of keeping it quiet, her own 
health must soon suffer, to say nothing of the discomfort of being 
incessantly tied to the child's side ; while the child itself has not 
sufficient rest to digest its food, and, very shortly, diarrhoea, or other 
symptoms of dyspepsia, are pretty sure to follow. After a month or 
two the infant should be trained to require the breast less often at 
night, so as to enable the mother to have an undisturbed sleep of six 
or seven hours. For this purpose she should arrange the times of 
nursing so as to give the breast just before she goes to bed, and not 
again until the early morning. If the child should require food in 
the interval, a little milk and water, from the bottle, may be advan- 
tageously given. 

Diet of Nursing Women. — The diet of the nursing woman should be 
arranged on ordinary principles of hygiene. It should be abundant, 
simple, and nutritious, and all rich and stimulating articles of food 
should be avoided. A common error in the diet of wet nurses is 
over-feeding, which constantly leads to deterioration of the milk. 
Many of these women, before entering on their functions, have been 
living on the simplest and even sparest diet, and not uncommonly, 
in the better class of houses, they are suddenly given heavy meat 
meals three and even four times a day, and often three or four glasses 
of stout. It is hardly a matter of astonishment that, under such cir- 
cumstances, their milk should be found to disagree. For a nursing 
woman in good health tivo good meat meals a day, with two glasses 
of beer or porter, and as much milk and bread and butter as she 
likes to take in the interval, should be amply sufficient. 1 Plenty of 
moderate exercise should be taken, and the more nurse and child are 
out in the open air, provided the weather be reasonably fine, the 
better it is for both. 

Signs of Successful Lactation. — Carried on methodically in this 
manner, wet nursing should give but little trouble. In the intervals 
between its meals the child sleeps most of its time, and wakes with 
regularity to feed ; but if the child be wakeful and restless, cry after 
feeding, have disordered bowels, and, above all, if it do not gain, 
week by week, in weight (a point which should be, from time to 
time, ascertained by the scales), w r e may conclude that there is either 
some grave defect in the management of suckling, or that the milk 
is not agreeing. Should this unsatisfactory progress continue, in spite 
of our endeavors to remedy it, there is no resource left but the alter- 
ation of the diet, either by changing the nurse, or by bringing up 
the child by hand. The former should be preferred whenever it is 

[* A wet nurse should with us have three regular meals, no stimulants at all; milk 
to drink if needed; moderate exercise, and be taught to nurse at regular iutervals. — 
Ed.] 



540 THE PUERPERAL STATE. 

practicable, aud, in the upper ranks of life, it is by no means rare to 
have to change the wet nurse two or three times, before one is met 
with whose milk agrees perfectly. If the child have reached six or 
seven months of age, it may be preferable to wean it altogether, 
especially if the mother have nursed it, as hand-feeding is much 
less objectionable if the infant have had the breast for even a few 
months. 

Period of Weaning. — As a rule, weaning should not be attempted 
until dentition is fairly established, that being the sign that nature 
has prepared the child for an alteration of food ; and it is better that 
the main portion of the diet should be breast milk until at least six 
or seven teeth have appeared. This is a safer guide than any arbi- 
trary rule taken from the age of the child, since the commencement 
of dentition varies much in different cases. About the sixth or 
seventh month it is a good plan to commence the use of some suita- 
ble artificial food once a day, so as to relieve the strain on the mother 
or nurse, and prepare the child for weaning, which should always be 
a very gradual process. In this way a meal of rusks, of the entire 
wheat flour, or of beef- or chicken- tea, with bread crumb in it, may 
be given with advantage ; and, as the period for weaning arrives, a 
second meal may be added, and so eventually the child may be weaned 
without distress to itself, or trouble to the nurse. 

The Disorders of Lactation. — The disorders of lactation are nume- 
rous, and, as they frequently come under the notice of the practitioner, 
it is necessary to allude to some of the most common and important. 

Means of Arresting the Secretion of Milk. — The advice of the accou- 
cheur is often required in cases in which it has been determined that 
the patient is not to nurse, when we desire to get rid of the milk as 
soon as possible, or when, at the time of weaning, the same object is 
sought. The extreme heat and distension of the breasts, in the former 
class of cases, often give rise to much distress. A smart saline ape- 
rient will aid in removing the milk, and for this purpose a double 
Seidlitz powder, or frequent small doses of sulphate of magnesia, act 
well; while, at the same time, the patient should be advised to take 
as small a quantity of fluid as possible. Iodide of potassium in large 
doses, of 20 or 25 grains, repeated twice or thrice, has a remarkable 
effect in arresting the secretion of milk. This observation was first 
•empirically made by observing that the secretion of milk was arrested 
when this drug was administered for some other cause, and I have 
frequently found it answer remarkably well. The distension of the 
breasts is best relieved by covering them with a layer of lint or cotton 
wool, soaked in a spirit lotion, or eau de cologne and water, over 
which oiled silk is placed, and by directing the nurse to rub them 
gently with warm oil, whenever they get hard and lumpy. Breast- 
pumps and similar contrivances only irritate the breasts, and do more 
harm than good. The local application of belladonna has been strongly 
recommended as a means for preventing lacteal secretion. As usually 
applied, in the form of belladonna plaster, it is likely to prove 
hurtful, since the breast often enlarges after the plasters are applied, 
and the pressure of the unyielding leather on which they are spread 



ETC. 541 

produces intense suffering. A better way of using it is by rubbing 
down a drachm of the extract of belladonna with an ounce of glyce- 
rine, and applying this on lint. In some cases it answers extremely 
well ; bat it is very uncertain in its action, and frequently is quite 
useless. 

Defective Secretion of Milk. — A deficiency of milk in nursing 
mothers is a very common course of difficulty. In a wet nurse this 
drawback is, of cause, an indication for changing the nurse ; but to 
the mother the importance of nursing is so great, that an endeavor 
must be made either to increase the flow of milk, or to supplement it 
by other food. Unfortunately, little reliance can be placed on any of 
the so-called galactagogues. The only one which in recent times has 
attracted attention is the leaves of the castor oil plant, which, made 
into poultices and applied to the breast, are said to have a beneficial 
effect in increasing the flow of milk. 1 More reliance must be placed 
in a sufficiency of nutritious food, especially such as contains phos- 
phatic elements ; stewed eels, oysters, and other kinds of shell-fish, 
and the Eevalenta Arabica, are recommended by Dr. Routh, who 
has paid some attention to this point, 2 as peculiarly appropriate. If 
the amount of milk be decidedly deficient, the child should be less 
often applied to the breast, so as to allow milk to collect, and pro- 
perly prepared cow's milk from a bottle should be given alternately 
with the breast. This mixed diet generally answers well, and is far 
preferable to pure hand-feeding. 

De-pressed Nipples. — A not uncommon source of difficulty is a de- 
pressed condition of the nipples, which is generally produced by the 
constant pressure of the stays. The result is, that the. child, unable 
to grasp the nipple, and wearied with ineffectual efforts, may at last 
refuse the breast altogether. An endeavor should be made to elon- 
gate the nipple before putting it into the child's mouth, either by the 
fingers, or by some form of breast-pump, which here finds a useful 
indication. In the worst class of cases, when the nipple is perma- 
nently depressed, it may be necessary to let the child suck through 
a glass nipple-shield, to which is attached an india-rubber tube, 
similar to that of a sucking-bottle ; this it is generally well able 
to do. 

Fissures and excoriations of the nipples are common causes of suf- 
fering, in some cases leading to mammary abscess. Whenever the 
practitioner has the opportunity, he should advise his patient to 
prepare the nipple for nursing in the latter months of pregnancy; 
and this may best be done by daily bathing it with a spirituous or 
astringent lotion, such as eau de cologne and water, or a weak solu- 
tion of tannin. After nursing has begun, great care should be taken 
to wash and dry the nipple after the child has been applied to it, and, 
as long as the mother is in the recumbent position, she may, if the 

1 [Where milk agrees with the mother, it exceeds in virtue all other forms of diet. 
See article entitled " Milk as a Diet during Lactation," in Amer. Journ. of Obstet- 
rics, Feb. 1870, p. 675, by Ed.] 

2 Routh, On Infant- feeding. 



542 THE PUERPERAL STATE. 

nipples be at all tender, use zinc nipple-shields with advantage, when 
she is not nursing. In this way these troublesome complications may 
generally be prevented. The most common forms are either an abra- 
sion on the surface of the nipple, which, if neglected, may form a 
small ulcer, or a crack at some part of the nipple, most generally at 
its base. In either case, the suffering when the child is put to the 
breast is intense, sometimes indeed amounting to intolerable anguish, 
causing the mother to look forward with dread to the application of 
the child. Whenever such pain is complained of, the nipple should 
be carefully examined, since the fissure or sore is often so minute as 
to escape superficial examination. The remedies recommended are 
very numerous, and not always successful. Amongst those most 
commonly used are astringent applications, such as tannin, or weak 
solutions of nitrate of silver, or cauterizing the edges of the fissure 
with the solid nitrate of silver, or applying the flexible collodion of 
the Pharmacopoeia. Dr. Wilson, of Glasgow, speaks highly of a 
lotion composed of ten grains of nitrate of lead in an ounce of gly- 
cerine, which is to be applied after suckling, the nipple being care- 
fully washed before the child is again put to the breast. I have 
myself found nothing answer so well as a lotion composed of half an 
ounce of sulphurous acid, half an ounce of the glycerine of tannin, 
and an ounce of water, the beneficial effects of which are sometimes 
quite remarkable. Eelief may occasionally be obtained by inducing 
the child to suck through a nipple-shield, especially when there is 
only an excoriation ; but this will not always answer, on account of 
the extreme pain which it produces. 

Excessive Flow of Milk. — An excessive flow of milk, known as 
galactorrhea, often interferes with successful lactation. It is by no 
means rare in the first weeks after delivery for women of delicate 
constitution, who are really unfit to nurse, to be flooded with a super- 
abundance of watery and innutritious milk, which soon produces 
disordered digestion in the child. Under such circumstances, the 
only thing to be done is to give up an attempt which is injurious 
both to the mother and child. At a later stage the milk, secreted in 
large quantities, is sufficiently nourishing to the child, but the drain 
on the mother's constitution soon begins to tell on her. Palpitation, 
giddiness, emaciation, headache, loss of sleep, spots before the eyes, 
and even amaurosis, indicate the serious effects which are being pro- 
duced, and the absolute necessity of at once stopping lactation. When- 
ever, therefore, a nursing woman suffers from such symptoms, it is 
far better at once to remove the cause, otherwise a very serious and 
permanent deterioration of health might result. 

Mammary Abscess. — There is no more troublesome complication of 
lactation than the formation of abscess in the breast ; an occurrence 
by no means rare, and which, if improperly treated, may, by long- 
continued suppuration and the formation of numerous sinuses in and 
about the breast, produce very serious effects on the general health. 
The causes of breast abscess are numerous, and very trivial circum- 
stances may occasionally set up inflammation, ending in suppuration. 
Thus it may follow exposure to cold ; a blow, or other injury to the 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 543 

breast; some temporary engorgement of the lacteal tubes; or even 
sudden or depressing mental emotions. The most frequent cause is 
irritation from fissures or erosions of the nipples, which must, there- 
fore, always be regarded with suspicion, and cured as soon as possible. 

Signs and Symptoms. — The abscess may form in any part of the 
breast, or in the areolar tissue below it ; in the latter case, the in- 
flammation very generally extends to the gland structure. Abscess 
is usually ushered in by constitutional symptoms, varying in severity 
with the amount of the inflammation. Pyrexia is always present ; 
elevated temperature, rapid pulse, and much malaise and sense of 
feverishness, followed, in many cases, by distinct rigor, when deep- 
seated suppuration is taking place. On examining the breast it will 
be found to be generally enlarged and very tender, while, at the site 
of the abscess, an indurated and painful swelling may be felt. If the 
inflammation be chiefly limited to the subglandular areolar tissue, 
there may be no localized swelling felt, but the whole breast will be 
acutely sensitive, and the slightest movement will cause much pain. 
As the case progresses, the abscess becomes more and more super- 
ficial, the skin covering it is red and glazed, and, if left to itself, it 
bursts. In the more serious cases, it is by no means rare for multiple 
abscesses to form. These opening, one after the other, lead to the 
formation of numerous fistulous tracts, by which the breast may be- 
come completely riddled. Sloughing of portions of the gland-tissue 
may take place, and even considerable hemorrhage, from the de- 
struction of bloodvessels. The general health soon suffers to a 
marked degree, and, as the sinuses continue to suppurate for many 
successive months, it is by no means uncommon for the patient to be 
reduced to a state of profound and even dangerous debility. 

Treatment. — Much may be done by proper care to prevent the 
formation of abscess, especially by removing engorgement of the 
lacteal ducts, when threatened, by gentle hand friction in the manner 
already indicated. AYhen the general symptoms, and the local ten- 
derness, indicate that inflammation has commenced, we should at 
once endeavor to moderate it, in the hope that resolution may occur 
without the formation of pus. Here general principles must be 
attended to, especially giving the affected part as much rest as possi- 
ble. Feverishness may be combated by gentle saline, minute doses 
of aconite, and large doses of quinine ; while pain should be relieved 
by opiates. The patient should be strictly confined to bed, and the 
affected breast supported by a suspensory bandage. Warmth and 
moisture are the best means of relieving the local pain, either in the 
form of hot fomentations, or of light poultices of linseed-meal or 
bread and milk, and the breast may be smeared with extract of bella- 
donna rubbed down with glycerine, or the belladonna liniment 
sprinkled over the surface of the poultices. Generally the pain and 
irritation produced by putting the child to the breast are so great as 
to contra-indicate nursing from the affected side altogether, and we 
must trust to relieving the tension by poultices ; suckling being, in 
the mean time, carried on by the other breast alone. In favorable 
cases this is quite possible for a time, and it may be that, if the in- 



544 THE PUERPERAL STATE. 

flammation do not end in suppuration, or if the abscess be small and 
localized, the affected breast is again able to resume its functions. 
Often this is not possible, and it may be advisable, in severe cases, to 
give up nursing altogether. 

Pus should be Removed as soon as Possible. — The subsequent man- 
agement of the case consists in the opening of the abscess as soon as 
the existence of pns is ascertained, either by fluctuation, or, if the 
site of the abscess be deep-seated, by the exploring needle. It may 
be laid down as a principle, that the sooner the pus is evacuated the 
better, and nothing is to be gained by waiting until it is superficial. 
On the contrary, such delay only leads to more extensive disorgani- 
zation of tissue and the further spread of inflammation. 

Antiseptic Treatment. — The method of opening the abscess is of 
primary importance. It has always been customary simply to open 
the abscess at its most depending part, without using any precaution 
against the admission of air, and afterwards to treat secondary ab- 
scesses in the same way. The results are well known to all practical 
accoucheurs, and the records of surgery fully show how many weeks 
or months generally elapse in bad cases before recovery is complete. 
The antiseptic treatment of mammary abscess, in the way first 
pointed out by Lister, afford results which are of the most remark- 
able and satisfactory kind. Instead of being weeks and months in 
healing, I believe that the practitioner who fairly and minutely car- 
ries out Mr. Lister's directions may confidently look for complete 
closure of the abscess in a few days ; and I know nothing, in the 
whole range of my professional experience, that has given me more 
satisfaction than the application of this method to abscesses of the 
breast. The plan I first used is that recommended by Lister in the 
"Lancet" for 1867, but which is now superseded by his improved 
methods, which, of course, will be used in preference by all w r ho 
have made themselves familiar with the details of antiseptic surgery. 
The former, however, is easily within the reach of every one, and is 
so simple that no special skill or practice is required in its applica- 
tion ; whereas the more perfected antiseptic appliances will probably 
not be so readily obtained, and are much more difficult to use. I, 
therefore, insert Mr. Lister's original directions, which he assures me 
are perfectly aseptic, for the guidance of those who may not be able 
to obtain the more elaborate dressings: — "A solution of one part of 
crystallized carbolic acid in four parts of boiled linseed-oil having 
been prepared, a piece of rag from four to six inches square is dipped 
into the oily mixture, and laid upon the skin where the incision is to 
be made. The lower edge of the rag being then raised, while the 
upper edge is kept from slipping by an assistant, a common scalpel 
or bistoury dipped in the oil is plunged into the cavity of the ab- 
scess, and an opening about three-quarters of an inch in length is 
made, and the instant the knife is withdrawn the rag is dropped 
upon the skin as an antiseptic curtain, beneath which the pus flows 
out into a vessel placed to receive it. The cavity of the abscess is 
firmly pressed, so as to force out all existing pus as nearly as may be 
(the old fear of doing mischief by rough treatment of the pyogenic 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 545 

membrane being quite ill-founded); and if there be much, oozing of 
blood, or if there be considerable thickness of parts between the 
abscess and the surface, a piece of lint dipped in the antiseptic oil is 
introduced into the incision to check bleeding and prevent primary 
adhesion, which is otherwise very apt to occur. The introduction 
of the lint is effected as rapidly as may be, and under the protection 
of the antiseptic rag. Thus the evacuation of the original contents 
is accomplished with perfect security against the introduction of 
living germs. This, however, would be of no avail unless an anti- 
septic dressing could be applied that would effectually prevent the 
decomposition of the stream of pus constantly flowing out beneath it. 
After numerous disappointments, I have succeeded w T ith the follow- 
ing, which may be relied upon as absolutely trustworthy: About 
six teaspoonfuls of the above-mentioned solution of carbolic acid in 
linseed oil are mixed up with common whiting (carbonate of lime) 
to the consistence of a firm paste, which is, in fact, glazier's putty 
with the addition of a little carbolic acid. This is spread upon a 
piece of common tin-foil about six inches square, so as to form a 
layer about a quarter of an inch thick. The tin-foil, thus spread 
with putty, is placed upon the skin, so that the middle of it corre- 
sponds to the position of the incision, the antiseptic rag used in 
opening the abscess being removed the instant before. The tin is 
then fixed securely by adhesive plaster, the lowest edge being left 
free for the escape of the discharge into a folded towel placed over 
it and secured by a bandage. The dressing is changed, as a general 
rule, once in 24 hours, but, if the abscess be a very large one, it is 
prudent to see the patient 12 hours after it has been opened, when, 
if the towel should be much stained with discharge, the dressing 
should be changed, to avoid subjecting its antiseptic virtues to too 
severe a test. But after the first 24 hours a single daily dressing 
is sufficient. The changing of the dressing must be methodically 
done, as follows: A second similar piece of tin-foil having been 
spread with the putty, a piece of rag is dipped in the oily solution 
and placed on the incision the moment the first tin is removed. This 
guards against the possibility of mischief occurring during the cleans- 
ing of the skin with a dry cloth, and pressing out any discharge 
w r hich may exist in the cavity. If a plug of lint was introduced 
when the abscess was opened, it is removed under cover of the anti- 
septic rag, which is taken off at the moment when the new tin is to 
be applied. The same process is continued daily until the sinus 
closes." 

Treatment of Long -continued Suppuration and Fever. — If the case 
come under our care when the abscess has been long discharging, or 
when sinuses have formed, the treatment is directed mainly to pro- 
curing a cessation of suppuration and closure of the sinuses. For 
this purpose methodical strapping of the breast with adhesive plaster, 
so as to afford steady support and compress the opposing pyogenic 
surfaces, w r ill give the best results. It may be necessary to lay open 
some of the sinuses, or to inject tinct. iodi or other stimulating lotions, 
so as to moderate the discharge, the subsequent surgical treatment 



546 THE PUERPERAL STATE. 

varying according to the requirements of each case. As the drain 
on the system is great, and the constitutional debility generally pro- 
nounced, much attention must be paid to general treatment; and 
abundance of nourishing food, appropriate stimulants, and such 
medicines as iron and quinine, will be indicated. 

Hand-feeding. — In a considerable number of cases the inability of 
the mother to nurse the child, her invincible repugnance to a wet 
nurse, or inability to bear the expense, renders hand-feeding essen- 
tial. It is, therefore, of importance that the accoucheur should be 
thoroughly familiar with the best method of bringing up the child 
by hand, so as to be able to direct the process in the way that is 
most likely to be successful. 

Causes of Mortality hi Hand fed Children. — Much of the mortality 
following hand-feeding may be traced to unsuitable food. Among 
the poorer classes especially there is a prevalent notion that milk 
alone is insufficient; and hence the almost universal custom of ad- 
ministering various farinaceous foods such as corn-flour or arrow- 
root, even from the earliest period. Many of these consist of starch 
alone, and are therefore absolutely unsuited for forming the staple 
of diet, on account of the total absence of nitrogenous elements. 
Independently of this, it has been shown that the saliva of infants 
has not the same digestive property on starch that it subsequently 
acquires, and this affords a further explanation of its so constantly 
producing intestinal derangement. Eeason, as well as experience, 
abundantly prove that the object to be aimed at in hand-feeding is 
to imitate as nearly as possible the food which nature supplies for 
the new-born child, and therefore the obvious course is to use milk 
from some animal, so treated as to make it resemble human milk 
as nearly as may be. 

Ass's Milk. — Of the various milks used, that of the ass, on the 
whole, most closely resembles human milk, containing less casein 
and butter, and more saline ingredients. It is not always easy to 
obtain, and in towns is excessively expensive. Moreover, it does not 
always agree with the child, being apt to produce diarrhoea. We 
can, however, be more certain of its being unadulterated, which in 
large cities is in itself no small advantage, and it may be given with- 
out the addition of water or sugar. 

Goafs milk in this country is still more difficult to obtain, but it 
often succeeds admirably. In many places the infant sucks the teat 
directly, and certainly thrives well on the plan. 

Cow's Milk and its Preparation. — In a large majority of cases we 
have to rely on cow's milk alone. It differs from human milk in 
containing less water, a larger amount of casein and solid matters, 
and less sugar. Therefore, before being given, it requires to be 
diluted and sweetened. A common mistake is over- dilution, and it 
is far from rare for nurses to administer one-third cow's milk to two- 
thirds water. The result of this excessive dilution is, that the child 
becomes pale and puny, and has none of the firm and plump appear- 
ance of a well-fed infant. The practitioner should, therefore, ascer- 
tain that this mistake is not being made; and the necessary dilution 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 547 

will be best obtained by adding to pure fresh, cow's milk, one- third 
hot water, so as to warm the mixture to about 96°, the whole being 
slightly sweetened with sugar of milk, or ordinary crystallized sugar. 
After the first two or three months the amount of water may be 
lessened, and pure milk, warmed and sweetened, given instead. 1 
Whenever it is possible, the milk should be obtained from the same 
cow, and in towns some care is requisite to see that the animal is 
properly fed and stabled. Of late years it has been customary to 
obviate the difficulties of obtaining good fresh milk by using some 
of the tinned milks now so easily to be had. These are already 
sweetened, and sometimes answer well, if not given in too weak a 
dilution. One great drawback in bottle-feeding is the tendency of 
the milk to become acid, and hence to produce diarrhoea. This may 
be obviated to a great extent by adding a tablespoonful of lime-water 
to each bottle, instead of an equal quantity of water. 

Artificial Human Milk. — An admirable plan of treating cow's milk, 
so as to reduce it to almost absolute chemical identity with human 
milk, has been devised by Professor Frankland, to whom I am in- 
debted for permission to insert the receipt. I have followed this 
method in many cases, and find it far superior to the usual one, as 
it produces an exact and uniform compound. With a little practice 
nurses can employ it with no more trouble than the ordinary mixing 
of cow's milk with water and sugar. The following extract from 
Dr. Frankland's work 2 will explain the principles on which the pre- 
paration of the artificial human milk is founded: "The rearing of 
infants who cannot be supplied with their natural food is notoriously 
difficult and uncertain, owing chiefly to the great difference in the 
chemical composition of human milk and cow's milk. The latter is 
much richer in casein and poorer in milk-sugar than the former, 
whilst asses' milk, which is sometimes used for feeding infants, is 
too poor in casein and butter, although the proportion of sugar is 
nearly the same as in human milk. The relations of the three kinds 
of milk to each other are clearly seen from the following analytical 
numbers, which express the percentage amounts of the different 
constituents : — 

Casein ...... 

Butter ...... 

Milk-sugar ..... 

Salts 

These numbers show that by the removal of one-third of the casein 
from cow's milk and the addition of about one -third more milk-sugar, 
a liquid is obtained which closely approaches human milk in compo- 
sition, the percentage amounts of the four chief constituents being 
as follows: — 

L 1 The milk of the Alderney cow is too rich in butter for a young infant. Milk 
from one cow is often a trick of the vendor. A selected animal should be neither 
young nor old, and of common stock, having had two or three calves, and healthy. 
— Ed.] 

2 Frankland's Experimental Researches in Chemistry, p. 843. 



oman. 


Ass. 


Cow. 


2.7 


1.7 


4.2 


3.5 


1.3 


3.8 


5.0 


4.5 


3.8 


.2 


.5 


.7 



548 THE PUERPERAL STATE. 

Casein 2.8 

Butter 3.8 

Milk-sugar .......... 5.0 

Salts 7 

The following is the mode of preparing the milk : Allow one-third 
of a pint of new milk to stand for about twelve hours, remove the 
cream, and add to it two-thirds of a pint of new milk, as fresh from 
the cow as possible. Into the one- third of a pint of blue milk left 
after the abstraction of the cream put a piece of rennet about one 
inch square. Set the vessel in warm water until the milk is fully 
curdled, an operation requiring from five to fifteen minutes, accord- 
ing to the activity of the rennet, which should be removed as soon 
as the curdling commences, and put into an egg-cup for use on sub- 
sequent occasions, as it may be employed daily for a month or two. 
Break up the curd repeatedly, and carefully separate the whole of 
the whey, which should then be rapidly heated to boiling in a small 
tin pan placed over a spirit or gas lamp. During the heating a 
further quantity of casein technically called "fleetings" separates, 
and must be removed by straining through muslin. Now dissolve 
110 grains of powdered sugar of milk in the hot whey, and mix it 
with the two-thirds of a pint of new milk to which the cream from 
the other third of a pint was added as already described. The arti- 
ficial milk should be used within twelve hours of its preparation, 
and it is almost needless to add that all the vessels employed in its 
manufacture and administration should be kept scrupulously clean. 

Method of Hand-feeding. — Much of the success of bottle-feeding 
must depend on minute care and scrupulous cleanliness, points which 
cannot be too strongly insisted on. Particular attention should be 
paid to preparing the food fresh for every meal, and to keeping the 
feeding-bottle and tubes constantly in water when not in use, so that 
minute particles of milk may not remain about them and become 
sour. A neglect of this is one of the most fertile sources of the 
thrush from which bottle-fed infants often suffer. The particular 
form of bottle used is not of much consequence. Those now com- 
monly employed, with a long india-rubber tube attached, are prefer- 
able to the older forms of flat bottle, as thej^ necessitate strong 
suction on the part of the infant, thus forcing it to swallow the food 
more slowly. Care must be taken to give the meals at stated periods, 
as in breast-feeding, and these should be at first about two hours 
apart, the intervals being gradually extended. The nurse should be 
strictly cautioned against the common practice of placing the bottle 
beside the infant in its cradle, and allowing it to suck to repletion, a 
practice which leads to over-distension of the stomach, and conse- 
quent dyspepsia. The child should be raised in the arms at the 
proper time, have its food administered, and then be replaced in the 
cradle to sleep. In the first few weeks of bottle-feeding constipation 
is very common, and may be effectually remedied by placing as 
much phosphate of soda as will lie on a threepenny-piece in the 
bottle, two or three times in the twenty-four hours. 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 549 

Other hinds of Food. — If this system succeed, no other food should 
be given until the child is six or seven months old, and then some 
of the various infant's foods may be cautiously commenced. Of these 
there are an immense number in common use ; some of which are 
good articles of diet, others are unfitted for infants. In selecting 
them we have to see that they contain the essential elements of nutri- 
tion in proper combination. All those, therefore, that are purely 
i starchy in character, such as arrowroot, corn-flour, and the like, 
I should be avoided ; while those that contain nitrogenous as well as 
I starchy elements, may be safely given. Of the latter the entire 
wheat flour, which contains the husks ground down with the wheat, 
generally answers admirably ; and of the same character are rusks, 
tops and bottoms, JSTestle's or Liebig's infant's food, and many others. 
If the child be pale and flabby, some more purely animal food may 
often be given twice a day, and great benefit may be derived from a 
single meal of beef, chicken, or veal tea, with a little bread crumb in 
it, especially after the sixth or seventh month. Milk, however, should 
still form the main article of diet, and should continue to do so for 
many months. 

Management -when Milk disagrees. — If the child be pale, flabby, and 
do not gain flesh, more especially if diarrhoea or other intestinal dis- 
turbance be present, we may be certain that hand- feeding is not an- 
swering satisfactorily, and that some change is required. If the child 
be not too old, and will still take the breast, that is certainly the 
best remedy, but, if that be not possible, it is necessary to alter the 
I diet. When milk disagrees, cream, in the proportion of one table- 
! spoonful to three of water, sometimes answers well. Occasionally 
I also Liebig's infant's food, when carefully prepared, renders good 
service. Too often, however, when once diarrhoea or other intesti- 
nal disturbance has set in, all our efforts may prove unavailing, and 
the health, if not the life, of the infant becomes seriously imperilled. 
It is not, however, within the scope of this work to treat of the dis- 
orders of infants at the breast, the proper consideration of which re- 
quires a large amount of space, and I, therefore, refrain from making 
any further remarks on the subject. 

[As a general rule, children in this country are better kept exclu- 
j sively on a milk diet for at least 10 months, especially if it is in the 
summer season. The best addition then, is exsiccated wheat flour 
prepared by the process of Hards, and known as Hards' farinaceous 
food, prepared wheat, imperial granum, etc. Ohio groats made of 
the oat kernel, and prepared barley flour, are sometimes useful where 
the habit of the child is constipated. — Ed.] 



550 THE PUERPERAL STATE 






CHAPTEE III. 

PUERPERAL ECLAMPSIA. 

By the term puerperal eclampsia is meant a peculiar kind of epi- 
leptiform convulsions, which may occur in the latter months of preg- 
nancy, or during, or after parturition, and it constitutes one of the 
most formidable diseases with which the obstetrician has to cope. 
The attack is often so sudden and unexpected, so terrible in its 
nature, and attended with such serious danger both to the mother 
and child, that the disease has attracted much attention. 

Its Doubtful Etiology. — The researches of Lever, Braun, Frerichs, 
and many other writers who have shown the frequent association of 
eclampsia with albuminuria, have, of late years, been supposed to 
clear up to a great extent the etiology of the disease, and to prove 
its dependence on the retention of urinary elements in the blood. 
While the urinary origin of eclampsia has been pretty generally 
accepted, more recent observations have tended to throw doubt on 
its essential dependence on this cause; so that it can hardly be said 
that we are yet in a position to explain its true pathology with cer- 
tainty. These points will require separate discussion, but it is first 
necessary to describe the character and history of the attack. 

Considerable confusion exists in the description of puerperal con- 
vulsions from the confounding of several essentially distinct diseases 
under the same name. Thus, in most obstetric works, it has been 
customarv to describe three distinct classes of convulsion ; the epi- 
leptic, the hysterical, and the apoplectic. The two latter, however, 
come under a totally different category. A pregnant woman may 
suffer from hysterical paroxysms, or she may be attacked with apo- 
plexy, accompanied with coma, and followed by paralysis. But these 
conditions in the pregnant or parturient woman are identical with 
the same diseases in the non-pregnant, and are in no way special in 
their nature. True eclampsia, however, is different in its clinical 
history from epilepsy; although the paroxysms, while they last, are 
essentially the same as those of an ordinary epileptic fit. 

Premonitory Symptoms. — An attack of eclampsia seldom occurs 
without having been preceded by certain more or less well-marked 
precursory symptoms. It is true that, in a considerable number of 
cases, these are so slight as not to attract attention, and suspicion is 
not aroused until the patient is seized with convulsions. Still, sub- 
sequent investigations will very generally show that some symptoms 
did exist, which, if observed and properly interpreted, might have 
put the practitioner on his guard, and possibly enabled him to ward 
off the attack. Hence a knowledge of them is of real practical value. 
The most common are associated with the cerebrum, such as severe 



PUERPERAL ECLAMPSIA. 551 

headache, which is the one most generally observed, and is sometimes 
limited to one side of the head. Transient attacks of dizziness, spots 
before the eyes, loss of sight, or impairment of the intellectual facul- 
ties, are also not uncommon. These signs in a pregnant woman are 
of the gravest import, and should at once call for investigation into 
the nature of the case. Less marked indications sometimes exist in 
the form of irritability, slight headache or stupor, and a general feel- 
ing of indisposition. Another important premonitory sign is oedema 
of the subcutaneous cellular tissue, especially of the face or upper 
extremities, which should at once lead to an examination of the 
urine. 

Symptoms of the Attack. — Whether such indications have preceded 
an attack or not, as soon as the convulsion comes on there can no 
longer be any doubt as to the nature of the case. The attack is gene- 
rally sudden in its onset, and in its character is precisely that of a 

• severe epileptic fit, or of the convulsions in children. Close observa- 
tion shows that there is at first a short period of tonic spasm, affecting 
the entire muscular system. This is almost immediately succeeded 

;by violent clonic contractions, generally commencing in the muscles 
of the face, which twitch violently; the expression is horribly altered; 

I the globes of the eyes are turned up under the eyelids, so as to leave 
only the white sclerotics visible, and the angles of the mouth are 
retracted and fixed in a convulsive grin. The tongue is at the 
same time protruded forcibly, and, if care be not taken, is apt to be 
lacerated by the violent grinding of the teeth. The face, at first pale, 
soon becomes livid and cyanosed, while the veins of the neck are 
distended, and the carotids beat vigorously. Frothy saliva collects 
about the mouth, and the whole appearance is so changed as to render 
the patient quite unrecognizable. The convulsive movements soon 
attack the muscles of the body. The hands and arms, at first rigidly 
fixed, with the thumbs clenched into the palms, begin to jerk, and 
the whole muscular system is thrown into rapidly-recurring convul- 
sive spasms. It is evident that the involuntary muscles are impli- 
cated in the convulsive action, as well as the voluntary. This is 
shown by a temporary arrest of respiration at the commencement of 

{the attack, followed by irregular and hurried respiratory movements, 

J producing a peculiar hissing sound. The occasional involuntary ex- 

I pulsion of urine and feces indicates the same fact. During the attack 
the patient is absolutely unconscious, sensibility is totally suspended, 
and she has afterwards no recollection of what has taken place. For- 
tunately the convulsion is not of long duration, and, at the outside, 
does not last more than three or four minutes, generally not so long. 
In most cases, after an interval, there is a recurrence of the convul- 
sion, characterized by the same phenomena, and the paroxysms are 
repeated with more or less force and frequency according to the 
severity of the attack. Sometimes several hours may elapse before 
a second convulsion comes on ; at others the attacks may recur very 
often, with only a few minutes between them. In the slighter forms 

J of eclampsia there may not be more than 2 or 3 paroxysms in all; 

1 in the more serious as many as 50 or 60 have been recorded. 



552 THE PUERPERAL STATE. 

Condition between the Attacks. — After the first attack the patient 
generally soon recovers her consciousness, being somewhat dazed and 
somnolent, with no clear perception of what has occurred. If the 
paroxysms be frequently repeated, more or less profound coma con- 
tinues in the intervals between them, which, no doubt, depends upon 
intense cerebral congestion, resulting from the interference with the 
circulation in the great veins of the neck, produced by spasmodic 
contraction of the muscles. The coma is rarely complete, the patient 
showing signs of sensibility when irritated, and groaning during the 
uterine contractions. In the worst class of cases, the torpor may 
become intense and continuous, and in this state the patient may 
die. When the convulsions have entirely stopped, and the patient 
has completely regained her consciousness, and is apparently conva- 
lescent, recollection of what has taken place during, and some time 
before, the attack, may be entirely lost, and this condition may last 
for a considerable time. A curious instance of this once came under 
my notice in a lady who had lost a brother, to whom she was greatly 
attached, in the week immediately preceding her confinement, and 
in whom the mental distress seemed to have had a good deal to do 
in determining the attack. It was many weeks before she recovered 
her memory, and during that time she recollected nothing about the 
circumstances connected with her brother's death, the whole of that 
week being, as it were, blotted out of her recollection. 

Relation of the Attacks to Labor. — If the convulsions come on during 
pregnancy, we may look upon the advent of labor as almost a 
certainty ; and if we consider the severe nervous shock and general 
disturbance, this is the result we might reasonably anticipate. If 
they occur, as is not uncommon, for the first time during labor, the 
pains generally continue with increased force and frequency, since 
the uterus partakes of the convulsive action. It has not rarely 
happened that the pains have gone on with such intensity that the 
child has been born quite unexpectedly, the attention of the practi- 
tioner being taken up with the patient. In many cases the advent 
of fresh paroxysms is associated with the commencement of a pain, 
the irritation of which seems sufficient to bring on the convulsion. 

Results to the Mother and Child. — The results of eclampsia vary 
according to the severity of the paroxysms. It is generally said that 
about 1 in 3 or 4 cases dies. The mortality has certainly lessened of 
late years, probably in consequence of improved knowledge of the 
nature of the disease, and more rational modes of treatment. This 
is well shown by Barker, 1 who found in 1855 a mortality of 32 per 
cent, in cases occurring before and daring labor, and 22 per cent, in 
those after labor ; while since that date the mortality has fallen to 
14 per cent. The same conclusion is arrived at by Dr. Phillips, 2 
who has shown that the mortality has greatly lessened since the 
practice of repeated and indiscriminate bleeding, long considered the 
sheet anchor in the disease, has been discontinued, and the adminis- 
tration of chloroform substituted. 

1 The Puerperal Disease, p. 125. 2 Guy's Hosp. Reps., 1870. 



PUERPERAL ECLAMPSIA. 553 

Cause of Death. — Death may occur during the paroxysm, and then 
it may be due to the long continuance of the tonic spasm producing 
asphyxia. It is certain that, as long as the tonic spasm lasts, the 
respiration is suspended, just as in the convulsive disease of children 
known as laryngismus stridulus; and it is possible also that the heart 
may share in the convulsive contraction which is known to affect 
other involuntary muscles. More frequently, death happens at a 
later period, from the combined effects of exhaustion and asphyxia. 
The records of post-mortem examinations are not numerous; in those 
we possess the principal changes have been an anaemic condition of 
the brain, with some ©edematous infiltration. In a few rare cases 
the convulsions have resulted in effusion of blood into the ventricles, 
or on the base of the brain. The prognosis as regards the child is 
also serious. Out of 36 children, Hall Davis found 26 born alive, 
10 being still-born. There is good reason to believe that the con- 
vulsion may attack the child in utero ; of this several examples are 
mentioned by Cazeaux; or it may be subsequently attacked with 
convulsions, even when apparently healthy at birth. 

Pathology of the Disease. — -The precise pathology of eclampsia 
cannot be considered by any means satisfactorily settled. When, in 
the year 1843, Lever first showed that the urine in patients suffering 
from puerperal convulsions was generally highly charged with albu- 
men — a fact which subsequent experience has amply confirmed — it 
was thought that a key to the etiology of the disease had been found. 
It was known that chronic forms of Wright's disease were frequently 
associated with retention of urinary elements in the blood, and not 
rarely accompanied by convulsions. The natural inference was 
drawn, that the convulsions of eclampsia were also due to toxaemia 
resulting from the retention of urea in the blood, just as in the 
uraemia of chronic Bright's disease; and this view was adopted and 
supported by the authority of Braun, Frerichs, and many other 
writers of eminence, and was pretty generally received as a satisfac- 
tory explanation of the facts. Frerichs modified it so far, that he 
held that the true toxic element was not urea as such, but carbonate 
of ammonia, resulting from its decomposition; and experiments were 
made to prove that the injection of this substance into the veins of 
the lower animals produced convulsions of precisely the same cha- 
racter as eclampsia. Dr. Hammond, 1 of Maryland, subsequently 
made a series of counter experiments, which were held as proving 
that there was no reason to believe that urea ever did become de- 
composed in the blood in the way that Frerichs supposed, or that 
the symptoms of uraemia were ever produced in this way. Spiegel- 
berg 2 has, more recently, again examined the question both clinically, 
in a patient suffering from convulsions, in whose blood an excess of 
ammonia and urea was found, and by experiments on dogs, and 
maintains the accuracy of Frerichs's views. Others have believed 
that the poisonous elements retained in the blood are not urea or 
the products of its decomposition, but other extractive matters which 

1 Auier. Journ., 1861. 2 Arch. f. Gyn., 1870. 

36 



554 THE PUERPERAL STATE. 

have escaped detection. As time elapsed, evidence accumulated to 
show that the relation between albuminuria and eclampsia was not 
so universal as was supposed, or at least that some other factors 
were necessary to explain many of the cases. Numerous cases were 
observed in which albumen was detected in large quantities, without 
any convulsion following, and that, not only in women who had been 
the subject of Bright's disease before conception, but also when the 
albuminuria was known to have developed during pregnancy. Thus 
Imbert Goubeyre found that out of 164 cases of the latter kind, 95 
had no eclampsia; and Blot, out of 41 cases, found that 34 were 
delivered without untoward symptoms. It may be taken as proved, 
therefore, that albuminuria is by no means necessarily accompanied 
by eclampsia. Cases were also observed in which the albumen only 
appeared after the convulsion; and in these it was evident that the 
retention of urinary elements could not have been the cause of the 
attack ; and it is highly probable that in them the albuminuria was 
produced by the same cause which induced the convulsion. Special 
attention has been called to this class of cases by Braxton Hicks, 1 
who has recorded a considerable number of them. He says that the 
nearly simultaneous appearance of albuminuria and convulsion — and 
it is admitted that the two are almost invariably combined — must 
then be explained in one of three ways. 

1st. That the convulsions are the cause of the nephritis. 

2dly. That the convulsions and the nephritis 1 are producedj by the 
same cause, e. g., some detrimental ingredient circulating in the blood, 
irritating both the cerebro-spinal system and other organs at the 
same time. 

3dly. That the highly congested state of the venous system, in- 
duced by the spasm of the glottis in eclampsia, is able to produce the 
kidney complication. 

Theory of Traube and Rosenstein. — More recently Traube and Ko- 
senstein have advanced a theory of eclampsia, purporting to explain 
these anomalies. They refer the occurrence of eclampsia to acute 
cerebral anemia, resulting from changes in the blood incident to preg- 
nancy. The primary factor is the hydremic condition of the blood, 
which is an ordinary concomitant of the pregnant state, and, of course 
when there is also albuminuria, the watery condition of the blood is 
greatly intensified ; hence the frequent association of the two states. 
Accompanying this condition of the blood, there is increased tension 
of the arterial system, which is favored by the hypertrophy of the 
heart which is known to be a normal occurrence in pregnancy. The 
result of these combined states is a temporary hyperemia of the brain, 
which is rapidly succeeded by serous effusion into the cerebral tissues, 
resulting in pressure on its minute vessels, and consequent anaemia. 
There is much in this theory that accords with the most recent views 
as to the etiology of convulsive disease ; as, for example, the re- 
searches of Kussmaul and Tenner, who have experimentally proved 
the dependence of convulsion on cerebral anaBmia, and of Brown- 

1 Obstet. Trans., vol. viii. 



PUERPERAL ECLAMPSIA. 555 

Sequard, who showed that an asemic condition of the nerve-centres 
preceded an epileptic attack. It explains also very satisfactorily how 
the occurrence of labor should intensify the convulsions, since, during 
the acme of the pains, the tension of the cerebral arterial system is 
necessarily greatly increased. There are, however, obvious difficul- 
ties against its general acceptance. For example, it does not satis- 
factorily account for those cases which are preceded by well-marked 
precursory symptoms, and in which an abundance of albumen is 
present in the urine. Here the premonitory signs are precisely those 
which precede the development of uraemia in chronic Bright's disease, 
the dependence of which on the retention in the blood of urinary 
elements can hardly be doubted. 

Excitability of Nervous System. — The key to the liability of the 
puerperal woman to convulsive attacks is, do doubt, to be found in 
the peculiar excitable condition of the nervous system in pregnancy 
— a fact which was clearly pointed out by the late Dr. Tyler Smith, 
and by many other writers. Her nervous system is, in this respect, 
not unlike that of children, in whom the predominant influence and 
great excitability of the nervous system are well-established facts, and 
in whom precisely similar convulsive seizures are of common occur- 
rence on the application of a sufficiently exciting cause. 

Exciting Causes. — Admitting this, we require some cause to set 
the predisposed nervous system into morbid action ; and this we mav 
have either in a toxaemic, or in an extremely watery, condition of 
the blood, associated with albuminuria ; or along with these, or some- 
times independently of them, in some excitement, such as strong emo- 
tional disturbance. It is highly probable, however, that the theory 
of Traube affords a true insight into the actual condition of the nerve- 
centres — a fact of much practical importance in reference to treat- 
ment. 

Treatment. — The management of cases in which the occurrence of 
suspicious symptoms has led to the detection of albuminuria, has al- 
ready been fully discussed (p. 194.) We shall, therefore, here only 
consider the treatment of cases in which convulsions have actually 

I occurred. 

Venesection. — Until quite recently venesection was regarded as the 

j sheet anchor in the treatment, and blood was always removed copi- 
ously, and, there is sufficient reason to believe, with occasional re- 

I markable benefit. Many cases are recorded in which a patient, in 
apparently profound coma, rapidly regained her consciousness when 
blood was extracted in sufficient quantity. The improvement, how- 
ever, was often transient, the convulsions subsequently recurring with 
increased vigor. There are good theoretical grounds for believing 

I that blood-letting can only be of merely temporary use, aud may 
even increase the tendency to convulsion. These are so well put by 
Schroeder, that I cannot do better than quote his observations on 

J this point: — "If," he says, "the theory of Traube and Rosenstein be 

j correct, a sudden depletion of the vascular system, by which the 
pressure is diminished, must stop the attacks. From experience it is 
known that after venesection the quantity of blood soon becomes the 



556 THE PUERPERAL STATE. 

same through the serum taken from all the tissues, while the quality 
is greatly deteriorated by the abstraction of blood. A short time 
after venesection we shall expect to find the former blood-pressure 
in the arterial system, but the blood far more watery than previously. 
From this theoretical consideration it follows that abstraction of 
blood, if the above-mentioned conditions really cause convulsions, 
must be attended by an immediate favorable result, and, under cer- 
tain circumstances, the whole disease may surely be cut short by it. 
But, if all other conditions remain the same, the blood-pressure will 
after some time again reach its former height. The quantity of blood 
has, in the mean time, been greatly deteriorated, and consequently 
the danger of the disease will be increased." 

In Properly -selected Cases Venesection is a Valuable Remedy. — These 
views sufficiently well explain the varying opinions held with regard 
to this remedy, and enable us to understand why, while the effects 
of venesection have been so lauded by certain authors, the mortality 
has admittedly been much lessened since its indiscriminate use has 
been abandoned. It does not follow because a remedy, when carried 
to excess, is apt to be hurtful, that it should be discarded altogether; 
and I have no doubt that, in properly-selected cases, and judiciously 
employed, venesection is a valuable aid in the treatment of eclampsia, 
and that it is specially likely to be useful in mitigating the first 
violence of the attack, and in giving time for other remedies to come 
into action. Care should, however, be taken to select the cases 
properly, and it will be specially indicated when there is marked 
evidence of great cerebral congestion and vascular tension, such as 
a livid face, a full bounding pulse, and strong pulsation in the caro- 
tids. The general constitution of the patient may also serve as a 
guide in determining its use, and we shall be the more disposed to 
resort to it if the patient be a strong and healthy woman ; while, on 
the other hand, if she be feeble and weak, we may wisely discard it, 
and trust entirely to other means. In any case, it must be looked 
upon as a temporary expedient only ; useful in warding off immediate 
danger to the cerebral tissues, but never as the main agent in treat- 
ment. Nor can it be permissible to bleed in the heroic manner fre- 
quently recommended. A single bleeding, the amount regulated by 
the effect produced, is all that is ever likely to be of service. 

Compression of the Carotids. — As a temporary expedient, having 
the same object in view, compression of the carotids during the par- 
oxysms is worthy of trial. This was proposed by Trousseau in the 
eclampsia of infants, but I am not aware that it has been tried in 
puerperal convulsions. It is a simple measure, and it offers the ad- 
vantage of not leading to any permanent deterioration of the blood, 
as in venesection. 

Administration of Purgatives. — As a subsidiary means of diminish- 
ing vascular tension the administration of a strong purgative is de- 
sirable, and has the further effect of removing any irritant matter 
that may be lodged in the intestinal tract. If the patient be con- 
scious a full dose of the compound jalap powder may be given, or a 



PUERPERAL ECLAMPSIA. 557 

few grains of calomel combined with jalap; and if she be comatose, 
and unable to swallow, a drop of croton oil, or a quarter of a grain 
of elaterium, may be placed on the back of the tongue. 

Administration of Sedatives and Narcotics. — The great indication 
in the management of eclampsia is the controlling of convulsive action 
by means of sedatives. Foremost amongst them must be placed the 
inhalation of chloroform, a remedy which is frequently remarkably 
useful, and which has the advantage of being applicable at all stages 
of the disease, and whether the patient be comatose or not. Theo- 
retical objections have been raised against its employment, as being 
likely to increase cerebral congestion; of this there is no satisfactory 
proof; on the contrary, there is reason to think that chloroform 
inhalation has rather the effect of lessening arterial tension, while 
it certainly controls the violent muscular action by which the hyper- 
emia is so much increased. Practically no one who has used it can 
doubt its great value in diminishing the force and frequency of the 
convulsive paroxysms. Statistically its usefulness is shown by Char- 
pentier, in his thesis on the effects of various methods of treatment 
in eclampsia, since out of 63 cases in which it was used, in 48 it had 
the effect of diminishing or arresting the attacks, 1 only proving 
fatal. The mode of administration has varied. Some have given 
it almost continuously, keeping the patient in a more or less profound 
state of anaesthesia. Others have contented themselves with care- 
fully watching the patient, and exhibiting the chloroform as soon as 
there were any indications of a recurring paroxysm, with the view 
of controlling its intensity. The latter is the plan I have myself 
adopted, and of the value of which, in most cases, I have no doubt. 
Every now and again, cases will occur in which chloroform inhala- 
tion is insufficient to control the paroxysm, or in which, from the 
very cyanosed state of the patient, its administration seems contra- 
indicated. Moreover, it is advisable to have, if possible, some remedy 
more continuous in its action, and requiring less constant personal 
supervision. Latterly the internal administration of chloral has been 
recommended for this purpose. My own experience is decidedly in 
its favor, and I have used, as I believe, with marked advantage a 
combination of chloral with bromide of potassium, in the proportion 
of twenty grains of the former to half a drachm of the latter,' repeated 
at intervals of from four to six hours. 1 If the patient be unable to 
swallow, the chloral may be given in an enema. The remarkable 
influence of bromide of potassium in controlling the eclampsia of 
infants would seem to be an indication for its use in puerperal cases. 
Fordyce Barker is opposed to the use of chloral, which he thinks 
excites instead of lessening reflex irritability. 2 Another remedy, 
not entirely free from theoretical objections, but strongly recom- 
mended, is the subcutaneous injection of morphia, which has the 

[' We have used bromide of sodium and chloral with good effect ; but as the latter 
is an intoxicant, have used doses of 10 to 15 grains, and at shorter intervals. — Ed.] 
2 The Puerperal Diseases, p. 120. 



558 THE PUERPERAL STATE. 

advantage of being applicable when the patient is quite unable to 
swallow. It may be given in doses of one-third of a grain, repeated 
in a few hours, so as to keep the patient well under its influence. It 
is to be remembered that the object is to control muscular action, so 
as to prevent, as much as possible, the violent convulsive paroxysm, 
and, therefore, it is necessary that the narcosis, however produced, 
should be continuous. It is rational, therefore, to combine the inter- 
mittent action of chloroform with the more continuous action of other 
remedies, so that the former should supplement the latter when in- 
sufficient. 

Other remedies, supposed to act in the way of antidotes to urasmic 
poisoning, have been advised, such as acetic or benzoic acid, but 
they are far too uncertain to have any reliance placed on them, and 
they distract attention from more useful measures. 

Precautions during the Paroxysm. — Precautions are necessary 
during the fits to prevent the patient injuring herself, especially to 
obviate, laceration of the tongue ; the latter can be best done by 
placing something between the teeth as the paroxysm comes on, such 
as the handle of a teaspoon enveloped in several folds of flannel. 

Obstetric Management. — The obstetric management of eclampsia 
will naturally give rise to much anxiety, and on this point there has 
been considerable difference of opinion. On the one hand, we have 
practitioners who advise the immediate emptying of the uterus, even 
when labor has commenced ; on the other, those who would leave 
the labor entirely alone. Thus Gooch said, " attend to the convul- 
sions, and leave the labor to take care of itself ;" and Schroeder says, 
" especially no kind of obstetric manipulation is required for the 
safety of the mother," but he admits, however, that it is sometimes 
advisable to hasten the labor to insure the safety of the child. 

In cases in which the convulsions come on during labor, the pains 
are often strong and regular, the labor progresses satisfactorily, and 
no interference is needful. In others we cannot but feel that empty- 
ing the uterus would be decidedly beneficial. We have to reflect, 
however, that any active interference might, of itself, prove very irri- 
tating, and excite fresh attacks. The influence of uterine irritation 
is apparent, by the frequency with which the paroxysms recur with 
the pains. If, therefore, the os be undilated, and labor have not 
begun, no active means to induce it should be adopted, although the 
membranes may be ruptured with advantage, since that procedure 
tends to no irritation. Forcible dilatation of the os, and especially 
turning are strongly contra-indicated. 

The rule laid down by Tyler Smith seems that which is most ad- 
visable to follow — that we should adopt the course which seems least 
likely to prove a souce of irritation to the mother. Thus if the fits 
seems evidently induced and kept up by the pressure of the foetus, 
and the head be within reach, the forceps or even craniotomy may 
be resorted to. But if, on the other hand, there be reason to think 
that the operation necessary to complete delivery is likely per se to 
prove a greater source of irritation than leaving the case to nature, 
then we should not interfere. 



PUERPERAL INSANITY. 559 

[In one case of eclampsia in a primipara, the attacks were inter- 
mittent and lasted during the pains. As the labor progressed, the 
convulsions became more marked until the head of the foetus began 
to dilate the vulva, when they diminished and finally ceased. The 
forceps were ready for application, but were not required. — Ed.] 



CHAPTER IV. 

PUERPERAL INSANITY. 

Classification. — Under the head of u Puerperal Mania" writers on 
obstetrics have indiscriminately classed all cases of mental disease 
connected with pregnancy and parturition. The result has been 
unfortunate, for the distinction between the various types of mental 
disorder has, in consequence, been very generally lost sight of. But 
little study of the subject suffices to show that the term Puerperal 
Mania is wrong in more ways than one, for we find that a large 
number of cases are not cases of " mania" at all, but of melancholia; 
while a considerable number are not, strictly speaking, "puerperal," 
as they either come on during pregnancy, or long after the immediate 
risks of the puerperal period are over, being in the latter case asso- 
ciated with anaemia produced by over-lactation. For the sake of 
brevity, the generic term "Puerperal Insanity" may be employed to 
cover all cases of mental disorders connected with gestation, which 
may be further conveniently subdivided into three classes, each 
having its special characteristics, viz. : — 

I. The Insanity of Pregnancy. 

II. Puerperal Insanity, properly so called, that is insanity coming 
on within a limited period after delivery. 

III. The Insanity of lactation. 

This division is a strictly natural one, and includes all the cases 
likely to come under observation. The relative proportion these 
classes bear to each other can only be determined by accurate statis- 
tical observations on a large scale, but these materials we do not 
possess. The returns from large asylums are obviously open to 
objection, for only the worst and most confirmed cases find their way 
into these institutions, while by far the greater proportion, both 
before and after labor, are treated in their own homes. 

Taking such returns as only approximative, we find from Dr. 
Batty Tuke 1 that in the Edinburgh Asylum out of 105 cases of puer- 
peral insanity, 28 occurred before delivery, 13 during the puerperal 

1 Edin. Med. Journ., vol. x. 



560 THE PUERPERAL STATE. 

period, and 54 daring lactation. The relative proportions of each 
per hundred are as follows : — 

Insanity of Pregnancy, 8.06 per cent. 
Puerperal Insanity, 47.09 " 
Insanity of Lactation, 34. 8 " 

Marce 1 collects together several series of cases from various authori- 
ties, amounting to 310 in all, and the results are not very different 
from those of the Edinburgh Asylum, except in the relatively smal- 
ler number of cases occurring before delivery. The percentage is 
calculated from his figures — ■ 

Insanity of Pregnancy, 8.06 per cent. 
Puerperal Insanity, 58.06 " 
Insanity of Lactation, 30.30 " 

As each of these classes differs in various important respects from 
the others, it will be better to consider each separately. 

Insanity of Pregnancy. — The Insanity of Pregnancy is, without 
doubt, the least common of the three forms. The intense mental 
depression which in many women accompanies pregnancy, and causes 
the patient to take a desponding view of her condition, and to look 
forward to the result of her labor with the most gloomy apprehen- 
sion, seems to be often only a lesser degree of the actual mental 
derangement which is occasionally met with. The relation between 
the two states is further borne out by the fact that a large majority 
of cases of insanity during pregnancy are well-marked types of 
melancholia; out of 28 cases, reported by Tuke, 15 were examples 
of pure melancholia, 5 of dementia with melancholia. In many of 
these the attack could be traced as developing itself out of the ordi- 
nary hypochondriasis of pregnancy. In others the symptoms came 
on at a later period of pregnancy, the earlier months of which had 
not been marked by any unusual lowness of spirits. The age of the 
patient seems to have some influence, the proportion of cases between 
30 and 40 years of age being much larger than in younger women. 
A larger proportion of cases occur in primiparae than in multipara, 
a fact that, no doubt, depends on the greater dread and apprehension 
experienced by women who are pregnant for the first time, especially 
if not very young. Hereditary disposition plays an important part, 
as in all forms of puerperal insanity. It is not always easy to ascer- 
tain the fact of an hereditary taint, since it is often studiously con- 
cealed by the friends. Tuke, however, found distinct evidence of it 
in no less than 12 out of 28 cases. Fiirstner 2 believes that other 
neuroses have an important influence in the causation of the disease. 
Out of 32 cases he found direct hereditary taint in 9, but in 11 more 
there was a family history of epilepsy, drunkenness, or hysteria. 

Period of Pregnancy at which it Occurs. — The period of pregnancy, 
at which mental derangement most commonly shows itself, varies. 
Most generally, perhaps, it is at the end of the third, or the beginning 

1 Traite dc la Folic des Femmes enceintes. 

2 Arelriv fur Psychiatric, Band v. Heft 2. 



PUERPERAL INSANITY. 561 

of the fourth month. It may, however, begin with conception, and 
even return with every impregnation. Montgomery relates an in- 
stance in which it recurred in three successive pregnancies. Marce 
distinguishes between true insanity coming on during pregnancy, 
and aggravated hypochondriasis, by the fact that the latter usually 
lessens after the third month, while the former most commonly only 
begins after that date. It is unquestionable that in many cases no 
such distinction can be made, and that the two are often very inti- 
mately associated. 

Form of Insanity. — The form of insanity does not differ from ordi- 
nary melancholia. The suicidal tendency is generally very strongly 
developed. Should the mental disorder continue after delivery, the 
patient may very probably experience a strong impulse to kill her 
child. Moral perversions have been not uncommonly observed. 
Tuke especially mentions a tendency to dipsomania in the early 
months, even in women who have not shown any disposition to 
excess at other times. He suggests that this may be an exaggeration 
of the depraved appetite, or morbid craving, so commonly observed 
in pregnant women, just as melancholia may be a further develop- 
ment of lowness of spirits. Laycock mentions a disposition to "klep- 
tomania" as very characteristic of the disease. Casper 1 relates a 
curious case where this occurred in a pregnant lady of rank, and the 
influence of pregnancy, in developing an irresistible tendency, was 
pleaded in a criminal trial in which one of her petty thefts had 
involved her. 

Prognosis — The prognosis may be said to be, on the whole, favor- 
able. Out of Dr. Tuke's 28 cases, 19 recovered within six months. 
There is little hope of a cure until after the termination of the preg- 
nancy, as out of 19 cases recorded by Marce* only in 2 did the insanity 
disappear before delivery. 

Transient Mania during Delivery. — There is a peculiar form of 
mental derangement sometimes observed during labor, which is by 
some talked of as a temporary insanity. It may, perhaps, be more 
accurately described as a kind of acute delirium, produced, in the 
latter stage of labor, by the intensity of the suffering caused by the 
pains. According to Montgomery, it is most apt to occur as the head 
is passing through the os uteri, or, at a later period, during the ex- 
pulsion of the child. It may consist of merely a loss of control over 
the mind, during which the patient, unless carefully watched, might, 
in her agony, seriously injure herself or her child. Sometimes it 
produces actual hallucination, as in the case described by Tarnier, 
in which the patient fancied she saw a spectre standing at the foot 
of her bed, which she made violent efforts to drive away. This kind 
of mania, if it may be so called, is merely transitory in its character, 
and disappears as soon as the labor is over. From a rnedico-legal 
point of view it may be of importance, as it has been held by some 
that in certain cases of infanticide the mother has destroyed the child 
when in this state of transient frenzy, and when she was irrespon- 

1 Casper's Forensic Medicine, vol. iv. 



562 THE PUERPERAL STATE. 

sible for her acts. In the treatment of this variety of delirium we 
must, of course, try to lessen the intensity of the suffering, and it is 
in such cases that chloroform will find one of its most valuable 
applications. 

Puerperal Insanity [proper). — True puerperal insanity has always 
attracted much attention from obstetricians, often to the exclusion of 
other forms of mental disturbance connected with the puerperal 
state. We may define it to be, that form of insanity which comes 
on within a limited period after delivery, and which is probably in- 
timately connected with that process. Out of 73 examples of the 
disease tabulated by Dr. Tuke, only 2 came on later than a month 
after delivery, and in these there were other causes present, which 
might possibly remove them from this class. 

Although a large number of these cases assume the character of 
acute mania, that is by no means the only kind of insanity which is 
observed, a not inconsiderable number being well-marked examples 
of melancholia. The distinction between them was long ago pointed 
out by Gooch, whose admirable monograph on the disease contains 
one of the most graphic and accurate accounts of puerperal insanity 
that has yet been written. 

There are also some peculiarities as to the period at which these 
varieties of insanity show themselves, which, taken in connection 
with certain facts in their etiology, may eventually justify us in 
drawing a stronger line of demarcation between them than has been 
usual. It appears that cases of acute mania are apt to come on at a 
period much nearer delivery than melancholia. Thus Tuke found 
that all the cases of mania came on within sixteen days after delivery, 
and that all cases of melancholia developed themselves after that 
period. We shall presently see that one of the most recent theories 
as to the causation of the disease attributes it to some morbid condi- 
tion of the blood. Should further investigation confirm this supposi- 
tion, inasmuch as septic conditions of the blood are most likely to 
occur a short time after labor, it would not be an improbable hy- 
pothesis that cases of acute mania, occurring within a short time 
after labor, may depend on such septic causes, while melancholia is 
more likely to arise from general conditions favoring the develop- 
ment of mental disease. This must, however, be regarded as a mere 
speculation requiring further investigation. 

Causes. — Hereditary predisposition is very frequently met with, 
and a careful inquiry into the patient's history will generally show 
that other members of the family have suffered from mental derange- 
ment. Eeid found that out of 111 cases in Bethlehem Hospital there 
was clear evidence of hereditary taint in 45. Tuke made the same 
observation in 22 out of his 73 cases ; and, indeed, it is pretty gene- 
rally admitted by all alienist physicians that hereditary tendencies 
form one of the strongest predisposing causes of mental disturbance 
in the puerperal state. In a large proportion of cases circumstances 
producing debility and exhaustion, or mental depression, have pre- 
ceded the attack. Thus it is often found that patients attacked with 
it have have had post-partum hemorrhage, or have suffered from 



PUERPERAL INSANITY. 563 

some other conditions producing exhaustion, such as severe and com- 
plicated labor ; or they may have been weakened by over-frequent 
pregnancies, or by lactation during the early months of pregnancy. 
Indeed anaemia is always well marked in this disease. Mental condi- 
tions also are frequently traceable in connection with its production. 
Morbid dread during pregnancy, insufficient to produce insanity be- 
fore delivery, may develop into mental derangement after it. Shame 
and fear of exposure in unmarried women not unfrequentfy lead to 
it, as is evidenced by the fact that out of 2281 cases, gathered from 
the reports of various asylums, above 64 per cent, were unmarried. 1 
Sudden moral shocks or vivid mental impressions may be the deter- 
mining cause in predisposed persons. Gooch narratives an example 
of this in a lady who was attacked immediately after a fright pro- 
duced by a fire close to her house, the hallucinations in this case 
being all connected with light; and Tyler Smith that of another 
whose illness dated from the sudden death of a relative. The age of 
the patient has some influence, and there seems to be a decidedly 
greater liability at advanced ages, especially when such women are 
pregnant for the first time. 

Theory of its Dependence on Morbid State of the Blood. — The possi- 
bility of the acute form of puerperal insanity, coming on shortly 
after delivery, being dependent on some form of septicaemia is one 
which deserves careful consideration. The idea originated with Sir 
James Simpson, who found albumen in the urine of 4 patients. He 
suggested that this might probably indicate the presence in the blood 
of certain urinary constituents, which might have determined the 
attack, much in the same way as in eclampsia. Dr. Donkin subse- 
quently wrote an important paper, 2 in which he warmly supported 
this theory, and arrived at the conclusion, "that the accute danger- 
ous class of cases are examples of uraemic blood-poisoning, of which 
the mania, rapid pulse, and other constitutional symptoms are merely 
the phenomena ; and that the affection, therefore, ought to be termed 
uraemic or renal puerperal mania, in contradistiction to the other 
form of the disease." He also suggests that the immediate poison 
may be carbonate of ammonia, resulting from the decomposition of 
urea retained in the blood. It will be observed, therefore, that the 
pathological condition producing puerperal mania would, supposing 
this theory to be correct, be precisely the same as that which, at 
other times, is supposed to give rise to puerperal eclampsia. There 
can be no doubt that the patient, immediately after deliver}', is in a 
condition rendering her peculiarly liable to various forms of septic 
disease ; and it must be admitted that there is no inherent improba- 
bility in the supposition that some morbid material circulating in the 
blood may be the effective cause of the attack, in a person otherwise 
predisposed to it. It is also certain, as I have already pointed out, 
that there are two distinct classes of cases, differing according to the 
period after delivery at which the attack comes on. Whether this 
difference depends on the presence in the blood of some septic mat- 

1 Journ. of Mental Science, 1870-1, p. 159. 2 Edin. Med. Journ., vol. vii. 



56± THE PUERPERAL STATE. 

ter — especially urinary excreta — is a question which, our knowledge 
by no means justifies us in answering ; it is, however, one which well 
merits further careful study. 

Objections to this Theory. — It is only fair to point to some difficul- 
ties which appear to militate against the view which Dr. Donkin 
maintains. In the first place, the albuminuria is merely transient, 
while its supposed effects last for weeks or months. Sir James 
Simpson says, with regard to his cases : " I have seen all traces of 
albuminuria in puerperal insanity disappear from the urine within 
fifty hours of the access of the malady. The general rapidity of its 
disappearance is, perhaps, the principal, or, indeed, the only reason 
why this complication has escaped the notice of those physicians 
among us who devote themselves with such ardor and zeal to the 
treatment of insanity in our public asylums." This apparent anomaly 
Simpson attempts to explain by the hypothesis that, when once the 
ursemic poisoning has done its work, and set the disease in progress, 
the mania progresses of itself. This, however, is pure speculation ; 
and, in the supposed analogous case of eclampsia, the albuminuria 
certainly lasts as long as its effects. It is not easy to understand, 
also, why urasmic poisoning should in one case give rise to insanity, 
and in another to convulsions. For all we know to the contrary, 
transient albuminuria may be much more common after delivery than 
has been generally supposed, and further investigation on this point 
is required. Albumen is by no means unfrequently observed in the 
urine, for a short time, in various conditions of the body, without 
any serious consequences, as, for example, after bathing ; and we 
may too readily draw an unjustifiable conclusion from its detection in 
a few cases of mania. There are, however, many other kinds of blood- 
poisoning, besides uraemia, which may have an influence in the pro- 
duction of the disease, and it is to be hoped that future observations 
may enable us to speak with more certainty on this point. 

Prognosis. — The prognosis of puerperal insanity is a point which 
will always deeply interest those who have to deal with so distress- 
ing a malady. It may resolve itself into a consideration of the im- 
mediate risk to life, and of the chances of ultimate restoration of the 
mental faculties. It is an old aphorism of Goock's, and one the 
correctness of which is justified by modern experience, that "mania 
is more dangerous to life, melancholia to reason." It -has very gene- 
rally been supposed that the immediate risk to life in puerperal 
mania is not great, and, on the whole, this may be taken as correct. 
Tuke found that death took place, from all causes, in 10.9 of the 
cases under observation ; these, however, were all women who had 
been admitted into asylums, and in whom the attack may be assumed 
to have been exceptionally severe. Great stress was laid by Hunter 
and Gooch on extreme rapidity of the pulse, as indicating a fatal 
tendency. There can be no doubt that it is a symptom of great 
gravity, but by no means one which need lead us to despair of our 
patient's recovery. The most dangerous class of cases are those at- 
tended with some inflammatory complication ; and if there be marked 
elevation of temperature, indicating the presence of some such con- 



PUERPERAL INSANITY. 565 

comitant state, our prognosis must be more grave than when there 
is mere excitement of the circulation. 

Post-mortem Signs. — There are no marked post-mortem signs 
found in fatal cases to guide us in forming an opinion as to the nature 
of the disease. "No constant morbid changes," says Tyler Smith, 
" are found within the head, and most frequently the only condition 
found in the brain is that of unusual paleness and exsanguinity 
Many pathologists have also remarked upon the extremely empty 
condition of the bloodvessels, particularly the veins. 

Duration of the Disease. — -The duration of the disease varies con- 
siderably. Generally speaking, cases of mania do not last so long as 
melancholia, and recovery takes place within a period of three 
months, often earlier. Very few of the cases admitted into the 
Edinburgh Asylum remained there more than six months, and after 
that time the chances of ultimate recovery greatly lessened. When 
the patient gets well, it often happens that her recollection of the 
events occurring during her illness is lost ; at other times, the delu- 
sions from which she suffered remain, as, for example, in a case 
which was under my care, in which the personal antipathies which 
the patient formed when insane became permanently established. 

Insanity of Lactation. — 54 out of the 155 cases collected by Dr. 
Tuke were examples of the insanity of lactation, which would appear, 
therefore, to be nearly twice as common as that of pregnancy, but 
considerably less so than the true puerperal form. Its dependence 
on causes producing anaemia and exhaustion is obvious and well 
marked. In the large majority of cases it occurs in multipara who 
have been debilitated by frequent pregnancies, and by length of 
nursing. When occurring in primiparse, it is generally in women 
who have suffered from post-partum hemorrhage, or other causes of 
exhaustion, or whose constitution was such as should have contra - 
indicated any attempt at lactation. The bruit-de-diable is almost 
invariably present in the veins of the neck, indicating the im- 
poverished condition of the blood. 

The type is far more frequently melancholic than maniacal, and 
when the latter form occurs, the attack is much more transient than 
in true puerperal insanity. The danger to life is not great, especially 
if the cause producing debility be recognized and at once removed. 
There seems, however, to be more risk of the insanity becoming 
permanent than in the other forms. In 12 out of Dr. Tuke's cases 
the melancholia degenerated into dementia, and the patient became 
hopelessly insane. 

Symptoms. — The symptoms of these various forms of insanity are 
practically the same as in the non-pregnant state. 

Generally in cases of mania there is more or less premonitory in- 
dication of mental disturbance, which may pass unperceived. The 
attack is often preceded by restlessness and loss of sleep, the latter 
being a very common and well-marked symptom ; or, if the patient 
do sleep, her rest is broken and disturbed by dreams. Causeless 
dislikes to those around her are often observed ; the nurse, the hus- 
band, the doctor, or the child, becomes the object of suspicion, and, 



56Q THE PUERPERAL STATE. 

unless proper care be taken, the child may be seriously injured. As 
the disease advances, the patient becomes incoherent and rambling 
in her talk, and, in a fully -developed case, she is incessantly pouring 
forth an unconnected jumble of sentences, out of which no meaning 
can be made. Often some prevalent idea which is dwelling in the 
patient's mind can be traced running through her ravings, and it has 
been noticed that this is frequently of a sexual character, causing 
women of unblemished reputation to use obscene and disgusting lan- 
guage, which it is difficult to understand their even having heard. The 
tendency of such patients to make accusations impugning their own 
chastity was specially insisted on by many eminent authorities in a 
recent celebrated trial, when Sir James Simpson stated that in his 
experience "the organ diseased gave a type to the insanity, so that 
with women suffering from affections of the genital organs the de- 
lusions would be more likely to be connected with sexual matters." 
Eeligious delusions, as a fear of eternal damnation, or of having 
committed some unpardonable sin, are of frequent occurrence, but 
perhaps more often in cases which are tending to the melancholic 
type. There is generally intolerable restlessness, and the patient's 
whole manner and appearance are those of excessive excitement. 
She may refuse to remain in bed, may tear off her clothes, or attempt 
to injure herself. The suicidal tendency is often very marked. In 
one case under my care, the patient made incessant efforts to destroy 
herself, which were only frustrated by the most careful watching ; 
she endeavored to strangle herself with the bedclothes, to swallow any 
article she could lay hold of, and even to gouge out her own eyes. 
Food is generally persistently refused, and the utmost coaxing may 
fail in inducing the patient to take nourishment. The pulse is rapid 
and small, and the more violent the excitement and furious the de- 
lirum, the more excited is the circulation. The tongue is coated and 
furred, the bowels constipated and disordered, and the feces, as well 
as the urine, are frequently passed involuntarily. The urine is 
scanty and high-colored, and, after the disease has lasted for some 
time, it becomes loaded with phosphates. The lochia, and the se- 
cretion of milk, generally become arrested at the commencement of 
the disease. The waste of tissue, from the incessant restlessness and 
movement of the patient, is very great; and, if the disease continue 
for some time, she falls into a condition of marasmus, which may be 
so excessive, that she becomes wasted to a shadow of her former 
size. 

Symptoms of Melancholia — When the insanity assumes the form 
of melancholia, its advent is more gradual. It may commence with 
depression of spirits, without any adequate cause, associated with in- 
somnia, disturbed digestion, headache, and other indications of bodily 
derangement. Such symptoms, showing themselves in women who 
have been nursing for a length of time, or in whom any other evident 
cause of exhaustion exists, should never pass unnoticed. Soon the 
signs of mental depression increase, and positive delusions show them- 
selves. These may vary much in their amount, but they are all more 
or less of the same type, and very often of a religious character. The 



PUERPERAL INSANITY. 567 

amount of constitutional disturbance varies much. In some cases 
which approach in character those of mania, there is considerable 
excitement, rapid pulse, furred tongue, and restlessness. Probably 
cases of acute melancholia, coming on during the puerperal state, 
most often assume this form. In others again there is less of these 
general symptoms, the patients are profoundly dejected, sit for hours 
without speaking or moving ; but there is not much excitement, and 
this is the form most generally characterizing the insanity of lacta- 
tion. In all cases there is a marked disinclination to food. There 
is also, almost invariably, a disposition to suicide ; and it should 
never be forgotten in melancholic cases that this may develop itself 
in an instant, and that a moment's carelessness on the part of the at- 
tendants may lead to disastrous results. 

Treatment. — Bearing in mind what has been said of the essential 
character of puerperal insanity, it is obvious that the course of treat- 
ment must be mainly directed to maintain the strength of the patient, 
so as to enable her to pass through the disease without fatal exhaus- 
tion of the vital powers, while we endeavor, at the same time, to calm 
the excitement, and give rest to the disturbed brain. Any over- 
active measures — for example, bleeding, blistering the shaven scalp, 
and the like — are distinctly contra-indicated. 

There is a general agreement on the part of the alienist physicians 
that in cases of acute mania the two things most needful are a suffi- 
cient quantity of suitable food and sleep. 

Importance of Adminstering Nourishment. — Every endeavor should 
be made to induce the patient to take abundance of nourishment, to 
remedy the effects of the excessive waste of tissue, and support her 
strength until the disease abates. Dr. Blandford, who has especially 
insisted on the importance of this, says, 1 "Now, with regard to the 
food, skilful attendants will coax a patient into taking a large quan- 
tity, and we can hardly give too much. Messes of minced meat with 
potato and greens, diluted with beef-tea, bread and milk, rum and 
milk, arrowroot, and so on, may be got down. Never give mere 
liquids so long as you can get down solids. As the malady pro- 
gresses, the tongue and mouth may become so dry and foul that 
nothing but liquids can be swallowed; but, reserving our beef- tea 
and brandy, let us give plenty of solid food while we can." 

Forcible Administration of Food. — The patient may in mania, as 
well as in. melancholia, perhaps even more in the latter, obstinately 
refuse to take nourishment at all, and we may be compelled to use 
force. Various contrivances have been employed for this purpose. 
One of the simplest is introducing a dessert-spoon forcibly between 
the teeth, the patient being controlled by an adequate number of 
attendants, and slowly injecting into the mouth suitable nourishment, 
by an india-rubber bottle with an ivory nozzle, such as is sold by all 
chemists. Care must be taken not to inject more than an ounce at 
a time, and to allow the patient to breathe between each deglutition. 
So extreme a measure will seldom be required, if the patient have 

1 Blandford, Insanity and its Treatment. 



568 THE PUERPERAL STATE. 

experienced attendants, who can overcome her resistance to food by 
gentler means; but it may be essential, and it is far better to employ 
it than to allow the patient to become exhausted from want of nour- 
ishment. In one case I had to feed a patient in this way three times 
a day for several weeks, and used for the purpose a contrivance 
known in asylums as Paley's feeding-bottle, which reduced the diffi- 
culty of the process to a minimum. Beef-tea, or strong soup, mixed 
with some farinaceous material, such as Revalenta Arabica, or wheaten 
flour, or milk, forms the best mess for this purpose. 

Stimulants. — In the early stages the patient is probably better 
without stimulants, which seem only to increase the excitement. As 
the disease progresses, and exhaustion becomes marked, it may be 
necessary to have recourse to them. In melancholia they seem to be 
more useful, and may be administered with greater freedom. 

State of the Bowels. — The state of the bowels requires especial 
attention. They are almost always disordered, the evacuations 
being dark and offensive in odor. In the early stages of the disease 
the prompt clearing of the bowels, by a suitable purgative, some- 
times has the effect of cutting short an impending attack. A curious 
example of this is recorded by Gooch, in which the patient's re- 
covery seemed to date from the free evacuation of the bowels. A 
few grains of calomel, or a dose of compound jalap powder, or of 
castor oil, may generally be readily given. During the continuance 
of the illness the state of the primae vise should be attended to, and 
occasional aperients will be useful, but strong and repeated purga- 
tion is hurtful from the debility it produces. 

The procuring sleep will necessarily form one of the most import- 
ant points of treatment. For this purpose there is no drug so valu- 
able as the hydrate of chloral, either alone, or in combination with 
bromide of potassium, which has a distinct effect in increasing its 
hypnotic action. Given in a full dose at bedtime, say 15 grs. to 3ss, 
it rarely fails in procuring at least some sleep, and, in an early stage 
of acute mania, this may be followed by the best effects. It may be 
necessary to repeat this draught night after night, during the acute 
stage of the malady. If we cannot induce the patient to swallow 
the medicine, it may be given in the form of enema. 

Question of Administering Opiates. — It is generally admitted that 
in mania preparations of opium, formerly much relied on in the 
treatment of the disease, are apt to do more harm than good. Dr. 
Blandford gives a strong opinion on this point. He says: "In pro- 
longed delirous mania I believe opium never does good, and may do 
great harm. We shall see the effects of narcotic poisoning if it be 
pushed, but none that are beneficial. This applies equally to opium 
given by the mouth and by subcutaneous injection. The latter, as 
it is more certain and effectual in producing good results, is also more 
deadly when it acts as a narcotic poison. After the administration 
of a dose of morphia by the subcutaneous method, the patient will 
probablv at once fall asleep, and we congratulate ourselves that our 
long wished-for object is attained. But after half an hour or so the 
sleep suddenly terminates, and the mania and excitement are worse 



PUERPERAL INSANITY. 569 

than before. Here yon may possibly think that had the dose been 
larger, instead of half an hour's sleep you would have obtained one 
of longer duration, and you may administer more, but with a like 
result. Large closes of morphia not merely fail to produce refreshing- 
sleep; they poison the patient, and produce, if not the symptoms of 
actual narcotic poisoning, at any rate that typhoid condition which 
indicates prostration and approaching collapse. I believe there is 
no drug, the use of which more often becomes abused, than that of 
opium." It is otherwise in cases of melancholia, especially in the 
more chronic forms. In these opiates, in moderate doses, not pushed 
to excess, may be given with great advantage. The subcutaneous 
injection of morphia is by far the best means of exhibiting the drug, 
from its rapidity of action, and facility of administration. 

Other Calmatives. — There are other methods of calming the excite- 
ment of the patient besides the use of medicines. The prolonged 
use of the warm bath, the patient being immersed in water at a 
temperature of 90° or 92° for at least half an hour, is highly recom- 
mended by some as a sedative. The wet pack serves the same pur- 
pose, and is more readily applied in refractory subjects. 

Importance of Judicious Nursing. — Judicious nursing is of primary 
importance. The patient should be kept in a cool, well ventilated, 
and somewhat darkened room. If possible she should remain in bed, 
or, at least, endeavors should be made to restrain the excessive rest- 
less motion, which has so much effect in promoting exhaustion. The 
presence of relatives and friends, especially the husband, has gene- 
rally a prejudicial and exciting effect; and it is advisable to place 
the patient under the care of nurses experienced in the management 
of the insane, who, as strangers, are likely to have more control over 
her. It is not too much to say that much of the success in treatment 
must depend on the manner in which this indication is met. Rough, 
unskilled nurses, who do not know how to use gentleness combined 
with firmness, will certainly aggravate and prolong the disorder. 
Inasmuch as no patient should be left unwatched by day or night, 
more than one nurse is essential. 

Question of Removal to an Asylum. — The question of the removal 
of the patient to an asylum is one which will give rise to anxious 
consideration. As the fact of having been under such restraint of 
necessity fixes a certain lasting stigma upon a patient, this is a step 
which every one would wish to avoid if possible. In cases of acute 
mania, which will probably last a comparatively short time, home 
treatment can generally be efficiently carried out. Much must depend 
on the circumstances of the patient. If these be of a nature which 
preclude the possibility of her obtaining thoroughly efficient nursing 
and treatment in her own home, it is advisable to remove her to a 
place where these essentials can be obtained, even at the cost of some 
subsequent annoyance. In cases of chronic melancholia, the mange- 
ment of which is on the whole more difficult, the necessity for such 
a measure is more likely to arise, and should not be postponed too 
late. Many examples of incurable dementia, arising out of puerperal 
37 



5T0 THE PUERPERAL STATE. 

melancholia, can be traced to unnecessary delay in placing the patients 
under the most favorable conditions for recovery. 

Treatment during Convalescence. — When convalescence is com- 
mencing, change of air and scene will often be found of great value. 
Removal to some quiet country place, where the patient can enjoy 
abundance of air and exercise, in the company of her nurses, with- 
out the excitement of seeing many people is especially to be recom- 
mended. Great caution must be used in admitting the visits of 
relatives and friends. In two cases under my own care the patients 
relapsed, when apparently progressing favorably, because the hus- 
bands insisted, contrary to advice, on seeing them. On the other 
hand, Grooch has pointed out that, when the patient is not recovering, 
when month after month has been passed in seclusion without any 
improvement, the visit of a friend or relative may produce a favor- 
able moral impression, and inaugurate a change for the better. It is 
probably in cases of melancholia, rather than in mania, that this is 
likely to happen. The experiment may, under such circumstances, 
be worth trying ; but it is one the result of which we must contem- 
plate with some anxiety. 



CHAPTER V. 

PUERPERAL SEPTICEMIA. 

There is no subject in the whole range of obstetrics which has 
caused so much discussion and difference of opinion as that to which 
this chapter is devoted. Under the name of " Puerperal Fever" the 
disease we have to consider has given rise to endless controversy. 
One writer after another has stated his view of the nature of the 
affection with dogmatic precision, often on no other grounds than his 
own preconceived notions, and an erroneous interpretation of some 
of the post-mortem appearances. Thus, one states that puerperal 
fever is only a local inflammation, such as peritonitis; others declare 
it to be phlebitis, metritis, metro-peritonitis, or an essential zymotic 
disease sui generis, which affects lying-in women only. The result 
has been a hopeless confusion ; and the student rises from the study 
of the subject with little more useful knowledge than when he began. 
Fortunately, modern research is beginning to throw a little light 
upon this chaos. 

Modern View of the Disease. — The whole tendency of recent inves- 
tigation is daily rendering it more and more certain that obstetri- 
cians have been led into error by the special virulence and intensity 
of the disease, and that they have erroneously considered it to be 
something special to the puerperal state, instead of recognizing in it 



PUERPERAL SEPTICEMIA. 571 

a form of septic disease practically inclentical with, that which is 
familiar to surgeons under the name of pyaemia or septicaemia. 

Objection to the Name. — If this view be correct, the term "puer- 
peral fever," conveying the idea of a fever such as typhus or typhoid, 
must be acknowledged to be misleading, and one that should be dis- 
carded, as only tending to confusion. Before discussing at length 
the reasons which render it probable that the disease is in no way 
specific, or peculiar to the puerperal state, it will be well to relate 
briefly some of the leading facts connected with it. 

History of the Disease. — More or less distinct references to the 
existence of the so-called puerperal fever are met with in the classical 
authors, proving, beyond doubt, that the disease was well known to 
them ; and Hippocrates, besides relating several cases the nature of 
which is unquestionable, clearly recognizes the possibility of* its 
originating in the retention and decomposition of portions of the 
placenta. Although Harvey and other writers showed that they 
were more or less familiar with it, and even made most creditable 
observations on its etiology, it was not until the latter half of the last 
century that it came prominently into notice. At that time the 
frightful mortality occurring in some of the principal lying-in hos- 
pitals, especially in the Hotel Dieu at Paris, attracted attention ; and 
ever since the disease has been familiar to obstetricians. 

Mortality resulting from it in Lying-in Hospitals. — Its prevalence 
in hospitals in which lying-in women are congregated has been con- 
stantly observed both in this country and abroad, occasionally pro- 
ducing an appalling death-rate ; the disease, when once it has 
appeared, frequently spreading from one patient to another, in spite 
of all that could be done to arrest it. It would be easy to give many 
startling instances of this. Thus it prevailed in London in the years 
1760, 1768, and 1770, to such an extent that in some lying-in insti- 
tutions nearly all the patients died. Of the Edinburgh Infirmary in 
1773, it is stated that " almost every woman, as soon as she was de- 
livered, or perhaps about twenty -four hours after, was seized with it, 
and all of them died, though every method was used to cure the dis- 
order." On the Continent, where the lying-in institutions are on a 
much larger scale, the mortality was equally great. Thus in the 
Maison d'Accouchements of Paris, in a number of different years, 
sometimes as many as 1 and 3 of the women delivered died ; on one 
occasion 10 women dying out of 15 delivered. Similar results were 
observed in other great Continental hospitals, as in Yienna, where, 
in 1823, 19 per cent, of the cases died, and, in 1812, 16 per cent. ; and 
in Berlin, in 1862, hardly a single patient escaped, the hospital being 
eventually closed. 

Such facts, the correctness of which is beyond any question, prove 
to demonstration the great risk which may accompany the aggrega- 
tion of lying-in women. Whether they justify the conclusion that 
all lying-in hospitals should be abolished, is another and a very wide 
question, which can scarcely be satisfactorily discussed in a practical 
work. It is to be observed, however, that most of the cases in which 
the disease produced such disastrous results, occurred before our more 



572 PUERPERAL STATE. 

recent knowledge of its mode of propagation was acquired, when no 
sufficient hygienic precautions were adopted, when ventilation was 
little thought of, and when, in a word, every condition prevailed 
that would tend to favor the spread of a contagious disease from one 
patient to another. More recent experience proves that when the 
contrary is the case (as for example in such an institution as the 
Kotunda Hospital in Dublin), the occurrence of epidemics of this 
kind may be entirely prevented, and the mortality approximated to 
that of home practice. 

The Assumption of a Puerperal Miasm is Unnecessary. — The more 
closely the history of these outbreaks in hospitals is studied, the 
more apparent does it become that they are not dependent on any 
miasm necessarily produced by the aggregation of puerperal patients, 
but on the direct conveyance of septic matter from one patient to 
another. 

In numerous instances the disease has been said to be generally 
epidemic in domiciliary practice, much in the same way as scarlet 
fever, or any other zymotic complaint, might be. Such epidemics 
are described as having occurred in London in 1827-28, in Leeds in 
1809-12, in Edinburgh in 1825, and many others might be cited. 
There is, however, no sufficient ground for believing that the disease 
has ever been epidemic in the strict sense of the word. That nume- 
rous cases have often occurred in the same place, and at the same 
time, is beyond question; but this can easily be explained without 
admitting an epidemic influence, knowing, as we do, how readily 
septic matter may be conveyed from one patient to another. In 
many of the so-called epidemics the disease has been limited to the 
patients of certain midwives or practitioners, while those of others 
have entirely escaped; a fact easily understood on the assumption 
of the disease being produced by septic matter conveyed to the 
patient, but irreconcilable with the view of general epidemic influ- 
ence. 

Numerous Theories advanced regarding its Nature. — It would be a 
useless task to detail at length the theories that have been advanced 
to explain the disease. Indeed it may safely be held that the sup- 
posed necessity of providing a theory which would explain all the 
facts of the disease has done more to surround it with obscurity than 
even the difficulties of the subject itself. If any real advance is to 
be made, it can only be by adopting an humble attitude, by admitting 
that we are only on the threshold of the inquiry, and by a careful 
observation of clinical facts, without drawing from them too positive 
deductions. 

Theory of its Local Origin. — Many have taught that the disease is 
essentially a local inflammation, producing secondary constitutional 
effects. This view doubtless originated from too exclusive attention 
to the morbid changes found on post-mortem examination. Exten- 
sive peritonitis, phlebitis, inflammation of the lymphatics, or of the 
tissues of the uterus, are very commonly found after death ; and each 
of these has, in its turn, been believed to be the real source of the 
disease. This view finds but little favor with modern pathologists, 



PUERPERAL SEPTICEMIA. 573 

and is in so many ways inconsistent with clinical facts, that it may 
be considered to be obsolete. No one of the conditions above men- 
tioned is universally found, and in the worst cases, definite signs of 
local inflammation may be entirely absent. Nor will this theory 
explain the conveyance of the disease from one patient to another, 
or the peculiar severity of the constitutional symptoms. 

Theory of an Essential Zymotic Fever. — A more admissible theory, 
and one which has been extensively entertained, is, that there is an 
essential zymotic fever peculiar to, and only attacking, puerperal 
women, which is as specific in its nature as typhus or typhoid, and 
to which the local phenomena observed after death bear the same 
relation that the pustules on the skin do to smallpox, or the ulcers 
in the intestinal glands to typhoid. This fever is supposed to spread 
by contagion and infection, and to prevail epidemically, both in 
private and in hospital practice. The most recent exponent of this 
view is Fordyce Barker, who, in his excellent work on the ''Puer- 
peral Diseases," has entered at length into all the theories of the 
disease. He, like others who hold his opinions, has, I cannot but 
think, entirely failed to bring forward any conclusive evidence of 
the existence of such a specific fever. It is no doubt true that in 
typhus and typhoid, and other undoubted examples of this class of 
disease, there are well-marked local secondary phenomena; but then 
they are distinct and constant. He makes no attempt to prove that 
anything 'of the kind occurs in puerperal fever. On the contrary, 
probably there are no two cases in which similar local phenomena 
occur; nor is there any case in which the most practised obstetrician 
could foretell, either the course and duration of the illness, or the 
local phenomena. Again, this theory altogether fails to explain the 
very important class of cases which can be distinctly traced to sources 
originating in the patient herself, viz., the absorption of septic matter 
from decomposing coagula, and the like. Barker meets this difficulty 
by placing such cases of auto-infection under a separate category, 
admitting that they are examples of septicaemia. But he fails to 
show that there is any difference in symptomatology or post-mortem 
signs between them and the cases he believes to depend on an essen- 
tial fever ; nor would it be possible to distinguish the one from the 
other by either their clinical or pathological history. 

Theory of Identity with Surgical Septicemia. — The modern view, 
which holds that the disease is, in fact, identical with the condition 
known as pyaemia or septicaemia, is by no means free from objections, 
and much patient clinical investigation is required to give a satisfac- 
tory explanation of certain peculiarities which the disease presents ; 
but, in spite of these difficulties, which time may serve to remove, it 
offers a far better explanation of the phenomena observed than any 
other that has yet been advanced. 

Nature of this View. — According to this theory the so-called puer- 
peral fever is produced by the absorption of septic matter into the 
system, through solutions of continuity in the generative tract, such 
as always exist after labor. It is not essential that the poison should 
be peculiar or specific; for, just as in surgical pyaemia, any decom- 



574 PUERPERAL STATE. 

posing organic matter, either originating within the generative organs 
of the patient herself, or coming from without, may set up the morbid 
action. 

In describing the disease under discussion, I shall assume that, so 
far as our present knowledge goes, this view is the one most conso- 
nant with facts ; but, bearing in mind that very little is yet known 
of surgical septicaemia, it must not be expected that obstetricians can 
satisfactorily explain all the phenomena they observe. 

Basis of Description. — The best basis of description I know of, is 
that given by Burdon Sanderson, when he says, "in every pyaemic 
process you may trace a focus, a centre of origin, lines of diffusion or 
distribution, and secondary results from the distribution. In every 
case an initial process from which infection commences, from which 
the infection spreads, and secondary processes which come out of 
this primary one." 1 Adopting this division, I shall first treat of 
the mode in which the infection may commence in obstetric cases, 
and point out the special difficulties which this part of the subject 
presents. 

Channels through which Septic Matter may be Absorbed. — The fact 
that all recently delivered women present lesions of continuity in the 
generative tract, through which septic matter, brought into contact 
with them, may be readily absorbed, has long been recognized. The 
analogy between the interior of the uterus after delivery and the 
surface of a stump after operation, was particularly insisted on by 
Cruvelhier, Simpson, and others ; an analogy which was, to a great 
extent, based on erroneous conceptions of what took place, since they 
conceived that the whole interior of the uterus was bared. It is now 
well known that that is not the case ; but the fact remains that at the 
placental site, at any rate, there are open vessels through which ab- 
sorption may readily take place. That absorption of septic material 
occurs through this channel is probable in certain cases in which 
decomposing materials exist in the interior of the uterus, especially 
when, from defective uterine contraction, the venous sinuses are ab- 
normally patulous, and are not occluded by thrombi. It is difficult 
to understand how septic matter, introduced from without, can reach 
the placental site. Other sites of absorption are, however, always 
available. These exist in every case in the form of slight abrasions 
or lacerations about the cervix, or in the vagina, or especially in 
primiparae, about the fourchette and perineum. There is even some 
reason to think that absorption of septic matter may take place 
through the mucous membrane of the vagina or cervix without any 
breach of surface. This might serve to account for the occasional, 
although rare, cases, in which symptoms of the disease develop them- 
selves before delivery, or so soon after it as to show that the infection 
must have preceded labor ; nor is ther ; any inherent improbability 
in the supposition that septic material may be occasionally absorbed 
through the unbroken mucous membrane, as is certainly the case 
with some poisons, for example that of syphilis. Hence there is no 

1 Clinical Transactions, vol. viii. p. cviii. 



PUERPERAL SEPTICEMIA. 575 

difficulty in recognizing the similarity of a lying-in woman to a pa- 
tient suffering from a recent surgical lesion, or in understanding how 
septic matter conveyed to her, during or shortly after labor, may be 
absorbed. It is necessary, however, to suppose that absorption takes 
place immediately or very shortly after these lesions of continuity 
are formed, for it is well known that the power of absorption is 
arrested after they have commenced to heal. This fact may explain 
the cases in which sloughing about the perineum or vagina exists 
without any septicaemia resulting, or the far from uncommon cases, 
in which an intensely fetid lochia! discharge may be present a few 
days after delivery, without any infection taking place. 

The character and sources of the septic matter constitute one of 
the most obscure questions in connection with septicaemia, and that 
which is most open to discussion. 

The most practical division of the subject is into cases in which 
the septic matter originates within the patient, so that she infects 
herself, the disease then being properly autogenetic ; and into those 
in which the septic matter is conveyed from without, and brought 
into contact with absorptive surfaces in the generative tract, the dis- 
ease then being hetero genetic. 

Sources of Self-infection. — The sources of auto-infection may be 
various, but they are not difficult to understand. Any condition 
giving rise to decomposition, either of the tissues of the mother 
herself, of matters retained in the uterus or vagina that ought to 
have been expelled, or decomposing matter derived from a putrid 
foetus, may start the septicaemic process. Thus it may happen that, 
from continuous pressure on the maternal soft parts during labor, 
sloughing has set in; or there may be already decomposing material 
present from some previous morbid state of the genital tracts, as in 
carcinoma. A more common origin is the retention of coagula, or 
of small portions of membrane, or of placenta, in the interior of the 
uterus, which have putrefied from access of air; or in the decompo- 
sition of the lochia. That the retention of portions of the placental 
tissue has at all times been the cause of septicaemia may be illustrated 
by the case of the Duchesse d'Orleans, in the time of Louis XIII., 
who had an easy labor, but died of child-bed fever. An examination 
was made by the leading physicians of Paris, in their report of which 
it was stated, " On the right side of the womb was found a small 
portion of after-birth, so firmly adherent that it could hardly be torn 
off' by the finger nails." 1 The reason why self-infection does not 
more often occur from sucli sources, since more or less decomposition 
is of necessity so often present, has already been referred to in the 
fact that absorption of such matters is not apt to occur when the 
lesions of continuity, always existing after parturition, have com- 
menced to heal. This observation may also serve to explain how 
previous bad states of health, by interfering with the healthy repa- 
rative process occurring after delivery, may predispose to self-infec- 
tion. It is interesting to note that puerperal septicaemia, arising 

1 Louise Bourgeois, by Goodell. 



576 PUERPERAL STATE. 

from such, sources, is not limited to the human race. In the debate 
on pysemia at the Clinical Society Mr. Hutchinson recorded several 
well-marked examples occurring in ewes, in whose uteri portions of 
retained placenta were found. 

Source of Heterogenetic Infection. — The sources of sceptic matter 
conveyed from without are much more difficult to trace, and there are 
many facts connected with heterogenetic infection which are very 
difficult to reconcile with theory, and of which, it must be admitted, 
we are not yet able to give a satisfactory explanation. 

It is probable that any decomposing organic matter may infect, 
but that some forms operate with more certainty and greater viru- 
lence than others. 

Influence of Cadaveric Poisoning. — One of these, which has attracted 
special attention, is what may be termed cadaveric poison, derived 
from dissection of the dead subject in the anatomical and post-mortem 
theatre, and conveyed to the genital tract by the hands of the accou- 
cheur. Attention was particularly directed to this source of infec- 
tion by the observations of Semmelweiss, who showed that in the 
division of the Vienna Lying-in Hospital attended by medical men 
and students who frequented the dissecting rooms, the mortality was 
seldom less than 1 in 10, while in the division solely attended by 
women, the mortality never exceeded 1 in 34 ; the number of deaths 
in the former division at once falling to that of the latter, as soon as 
proper precautions and means of disinfection were used. Many other 
facts of a like nature have since been recorded, which render this 
origin of puerperal septicaemia a matter of certainty. An interesting 
example is related by Simpson with characteristic candor: — "In 
1836 or 1337 Mr. Sidey of this city had a rapid succession of "five or 
six cases of puerperal fever in his practice, at a time when the dis- 
ease was not known to exist in the practice of any other practitioners 
in the locality. Dr. Simpson, who had then no firm or proper belief 
in the contagious propagation of puerperal fever, attended the dis- 
section of Mr. Sidey's patients, and freely handled the diseased parts. 
The next four cases of midwifery which Dr. Simpson attended were 
all affected with puerperal fever, and it w r as the first time he had 
seen it in practice. Dr. Patterson, of Leith, examined the ovaries, 
etc. The three next cases which Dr. Patterson attended in that town 
were attacked with the disease. 1 Negative examples are of course 
brought forward of those who have attended post-mortem examina- 
tions without injury to their obstetric patients, which merely prove 
that the cadaveric poison does not, of necessity, attach itself to the 
hands of the dissector ; and no amount of such testimony can invali- 
date such positive evidence as that just narrated. Barnes believes 
that there is not so much danger attending the dissection of patients 
who have died of any ordinary disease, but that the risk attending 
the dissection of those who have died of infectious or contagious 
complaints is very great indeed. 2 I presume there is no doubt that 

1 Selected Obst. Works, p. 508. 

2 "Lectures on Puerperal Fever," Lancet, vol. ii. 18G5. 



PUERPERAL SEPTICEMIA. 577 

the risk is greater when the subject has died from zymotic disease ; 
but the distinction is too delicate to rely on, and the attendant on 
midwifery will certainly err on the safe side by avoiding, as much as 
possible, having anything to do with the conduct of dissections or 
post-mortem examinations. 

Infection from Erysipelas. — Another possible source of infection is 
erysipelatous disease in all its forms. The intimate connection be- 
tween erysipelas and surgical pyaemia has long been recognized by 
surgeons, and the influence of erysipelas in producing puerperal 
septicaemia has been especially observed in surgical hospitals in 
which lying-in patients were also admitted. Trousseau relates in- 
stances of this kind occurring in Paris. The only instance that I 
know of in London was in the lying-in ward of King's College 
Hospital, where, in spite of every hygienic precaution, the mortality 
was so great as to necessitate the closure of the ward. Here the 
association of erysipelas with puerperal septicaemia was again "and 
again observed; the latter proving fatal in direct proportion to the 
prevalence of the former in the surgical wards. The dependence of 
the two on the same poison was in one instance curiously shown by 
the fact of the child of a patient wmo died of puerperal septicaemia, 

1 dying from erysipelas which started from a slight abrasion produced 
by the forceps. A more recent and very remarkable example is 
related by Dr. Lombe Atthill. 1 A patient suffering from erysipelas 
was admitted into the Eotunda Hospital on February 15, 1877. The 
sanitary condition of the hospital was at the time excellent. The 

I patient was removed next day; but of the next 10 patients confined 
in adjoining wards, 9 were attacked with puerperal peritonitis, the 

I only one who escaped being a case of abortion. But the connection 
between erysipelas and puerperal septicaemia is not limited to hospi- 
tals, having been often observed in domiciliary practice. Some 
interesting facts have been collected by Dr. Minor, 2 who has shown 
that the two diseases have frequently prevailed together in various 
parts of the United States, and that during a recent outbreak of 
puerperal fever in Cincinnati, it occurred chiefly in the practice of 
those physicians who attended cases of erysipelas. Many children 
also died from erysipelas, whose mothers had died from puerperal 
fever. 

Infection from other Zymotic Diseases. — There is good reason to 
believe that the contagium of other zymotic diseases may produce a 
form of disease indistinguishable from ordinary puerperal septicaemia, 
and presenting none of the characteristic features of the specific 
complaint from which the contagium was derived. This is admitted 
to be a fact by the majority of our most eminent British obstetri- 
cians, although it does not seem to be allowed by Continental authori- 
ties, and it is strongly controverted by some writers in this country. 
It is certainly difficult to reconcile this with the theory of septicae- 
mia, and we are not in a position to give a satisfactory explanation 

1 Medical Press and Circular, April, 187 7. 

2 Erysipelas and Childbed Fever. Cincinnati, 1874. 



578 PUERPERAL STATE. 

of it. I believe, however, that the evidence in favor of the possi- 
bility of puerperal septicemia originating in this way is too strong 
to be assailable. 

The scarlatinal poison is that regarding which the greatest number 
of observations have been made. Numerous cases of this kind are 
to be found scattered through our obstetric literature, but the largest 
number are to be met with in a paper by Dr. Braxton Hicks in the 
12th volume of the "Obstetrical Transactions," and they are especi- 
ally valuable from that gentleman's well-known accuracy as a clinical 
observer. Out of 68 cases of puerperal disease seen in consultation, 
no less than 37 were distinctly traced to the scarlatinal poison. Of 
these 20 had the characteristic rash of the disease ; but the remain- 
ing 17, although the history clearly proved exposure to the conta- 
gium of scarlet fever, showed none of its usual symptoms, and were 
not to be distinguished from ordinary typical cases of the so-called 
puerperal fever. On the theory that it is impossible for the specific 
contagious diseases to be modified by the puerperal state, we have to 
admit that one physician met with 17 cases of puerperal septicaemia 
in which, by a mere coincidence, the contagion of scarlet fever had 
been traced, and that the disease nevertheless originated from some 
other source; an hypothesis so improbable, that its mere mention 
carries its own refutation. 

With regard to the other zymotic diseases the evidence is not so 
strong ; probably from the comparative rarity of the diseases. Hicks 
mentions one case in which the diphtheritic poison was traced, al- 
though none of the usual phenomena of the disease were present. I 
lately saw a case in which a lady, a few days after delivery, had a 
very serious attack of septicemia, without any diphtheritic symp- 
toms, her husband being at the same time attacked with diphtheria 
of a most marked type. Here it would be difficult not to admit the 
dependence of the two diseases on the same poison. 

It is, however, certain that all the zymotic diseases may attack a 
newly delivered woman, and run their characteristic course without 
any peculiar intensity. Probably most practitioners have seen cases 
of this kind ; and this is precisely one of the points of difficulty 
which we cannot at present explain, but on which future research 
may be expected to throw some light. It seems to me not improba- 
ble, that the explanation of the fact that zymotic poison may in one 
puerperal patient run its ordinary course, and in another produce 
symptoms of intense septicemia, may be found in the channel of 
absorption. It is at any rate comprehensible that if the conta'gium 
be absorbed through the skin or the ordinary channels, it may pro- 
duce its characteristic symptoms, and run its usual course ; while if 
brought into contact with lesions of continuity in the generative 
tract, it may act more in the way of septic poison, or with such in- 
tensity that its specific symptoms are not developed. 

It may reasonably be objected that if puerperal and surgical sep- 
ticemia be identical, the zymotic poisons ought to be similarly modi- 
fied when they infect patients after surgical operations. The subject 
of specific contagium as a cause of surgical pyemia has been so little 



PUERPERAL SEPTICEMIA. 579 

studied, that I do not think any one would be justified in asserting 
that such an occurrence is not possible. Fritsch, of Halle, and other 
German physicians, have recently shown how elaborate antiseptic 
precautions in lying-in hospitals may prevent the origin of the dis- 
ease from such sources. Sir James Paget, in his " Clinical Lectures," 
seems to believe in the possibility of such modification. He says, 
" I think it not improbable that, in some cases, results occurring with 
obscure symptoms, within two or three days after operations, have 
been due to the scarlet-fever poison, hindered in some way from its 
usual progress." Mr. Spencer Wells informs me that he has seen 
cases of surgical pyaemia, which he had reason to believe originated 
in the scarlatinal poison ; and his well-known success as an ovario- 
tomist is, no doubt, in a great measure to be attributed to his extreme 
care in seeing that no one, likely to come in contact with his patients, 
has been exposed to any such source of infection. 

Septicaemia from Contagion convey eel from other Puerperal Patients. — 
The last source from which septic matter may be conveyed is from a 
patient suffering from puerperal septicaemia, a mode of origin which 
has, of late, attracted special attention. That this is the explanation 
of the occasional endemic prevalence of the disease in lying-in hos- 
pitals can scarcely be doubted. The theory of a special puerperal 
miasm pervading the hospital is not required to account for the facts, 
for there are a hundred ways, impossible to detect or avoid — on the 
hands of nurses or attendants, in sponges, bed-pans, sheets, or even 
suspended in the atmosphere — in which septic material, derived from 
one patient, may be carried to another. 

The poison may be conveyed, in the same manner, from one pri- 
vate patient to another. Of this there are many lamentable instances 
recorded. Thus it was mentioned by a gentleman at the recent dis- 
cussion at the Obstetrical Society, that 5 out of 14 women he attended 
died, no other practitioner in the neighborhood having a case. This 
origin of the disease was clearly pointed out by Gordon 1 towards the 
end of last century, who stated that he himself "was the means of 
carrying the infection to a great number of women," and he also 
traced the spread of the disease in the same way in the practice of 
certain midwives. In some remarkable instances the unhappy pro- 
perty of carrying contagion has clung to individuals in a way which 
is most mysterious, and which has led to the supposition that the 
whole system becomes saturated with the poison. One of the 
strangest cases of this kind was that of Dr. Rutter, of Philadelphia, 
which caused much discussion. He had 45 cases of puerperal septi- 
caemia in his own practice in one year, while none of his neighbors' 
patients were attacked. Of him it is related, "Dr. Rutter, to rid 
himself of the mysterious influence which seemed to attend upon 
his practice, left the city for ten days, and before waiting on the 
next parturient case had his hair shaved off, and put on a wig, took 
a hot bath, and changed every article of his apparel, taking nothing 
with him that he had worn or carried to his knowledge on any 

1 See Lectures on Puerperal Fever. By Robert J. Lee, M.D. 



580 PUERPERAL STATE. 

former occasion: and mark the result. The lady, notwithstanding 
that she had an easy parturition, was seized the next day with child- 
bed fever, and died on the eleventh day after the birth of the child. 
Two years later he made another attempt at self- purification, and the 
next case attended fell a victim to the same disease." No wonder 
that Meigs, in commenting on such a history, refused to believe that 
the doctor carried the poison, and rather thought that he was "merely 
unhappy in meeting with such accidents through God's providence." 
It appears, however, that Dr. Eutter was the subject of a form of 
ozoena, and it is quite obvious that, under such circumstances, his 
hands could never have been free from septic matter. 1 [The Author 
quotes from the Editor. Dr. Eutter had an ozoena which in time much 
disfigured him from its effect upon the contour of his nose. He was 
unfortunately inoculated in his index finger from a patient, and 
neglected the pustule. He had 95 cases of puerperal septicemia in 
4 years and 9 months, with 18 deaths. — Ed.] This observation is 
of peculiar interest as showing that the sources of infection may 
exist in conditions difficult to suspect and impossible to obviate, and 
it affords a satisfactory explanation of a case which was for years 
considered puzzling in the extreme. It is quite possible that other 
similar cases, of which many are on record, although none so re- 
markable, may possibly have depended on some similar cause per- 
sonal to the medical attendant. 

The sources of septic poison being thus multifarious, a few words 
may be said as to the mode in which it may be conveyed to the 
patient. 

Mode in which the Poison may be Conveyed to the Patient. — As on 
the view of puerperal septicaemia which seems most to agree with 
recorded facts, the poison, from whatever source it may be derived, 
must come into actual contact with lesions of continuity in the gene- 
rative tract, it is obvious that one method of conveyance may be on 
the hands of the accoucheur. That this is a possibility, and that the 
disease has often been unhappily conveyed in this way, no one can 
doubt. Still it would be unfair in the extreme to conclude that this 
is the only way in which infection may arise. In town practice, 
especially, there are many other ways in which septic matter may 
reach the patient. The nurse may be the means of communication, 
and, if she have been in contact with septic matter, she is even more 
likely than the medical attendant to convey it when washing the 
genitals during the first few days after delivery, the time that ab- 
sorption is most apt to occur. Barnes relates a whole series of cases 
occurring in a suburb of London, in the practice of different practi- 
tioners, every one of which was attended by the same nurse. Again 
septic matter may be carried in sponges, linen, and other articles. 
What is more likely, for example, than that a careless nurse might use 
an imperfectly washed sponge, on which discharge has been allowed 
to remain and decompose ? Nor do I see any reason to question the 

1 This is stated on the authority of an obstetrical contemporary of Dr. Rutter. 
See Amer. Journ. of Med. Sciences, April, 1875, p. 471. 



PUERPERAL SEPTICEMIA. 581 

possibility of infection from septic matter suspended in the atmos- 
phere; and in lying-in hospitals, where maiw women are congre- 
gated together, there can be little doubt that this is a common origin 
of the disease. It is certain, whatever view we may take of the 
character of the septic material, that it must be in a state of very 
minute subdivision, and there is no theoretical difficulty in the 
assumption of its being conveyed by the atmosphere. 

Conduct of the Practitioner in relation to the Disease. — This ques- 
tion naturally involves a reference to the duty of those who are 
unfortunately brought into contact with septic matter in any form, 
either in a patient suffering from puerperal septicaemia, zymotic dis- 
ease, or offensive discharges. The practitioner cannot always avoid 
such contact, and it is practically impossible, as Dr. Duncan has in- 
sisted, to relinquish obstetric work every time that he is in attendance 
on a case from which contagion may be carried. Nor do I believe, 
especially in these days when the use of antiseptics is so well under- 
stood, that it is essential. It was otherwise when antiseptics were 
not employed ; but I can scarcely conceive any case in which the 
risk of infection cannot be prevented by proper care. The danger I 
believe to be chiefly in not recognizing the possible risk, and in ne- 
glecting the use of proper precautions. It is impossible, therefore, 
to urge too strongly the necessity of extreme and even exaggerated 
care in this direction. The practitioner should accustom himself, as 
much as possible, to use the left hand Only in touching patients suf- 
fering from infectious diseases, as that which is not used, under ordi- 
nary circumstances, in obstetric manipulations. He should be most 
careful in the frequent employment of antiseptics in washing his 
hands, such as Condy's fluid, carbolic acid, or tincture of iodine. 
Clothing should be changed on leaving an infectious case. Much 
more care than is usually practised should be taken by nurses, espe- 
cially in securing perfect cleanliness in every thing brought into 
contact with the patient. When, however, a practitioner is in actual 
and constant attendance on a case of puerperal septicaemia, when he 
is visiting his patient many times a day, especially if he be himself 
washing out the uterus with antiseptic lotions, it is certain that be 
cannot deliver other patients with safety, and he should secure the 
assistance of a brother practitioner, although there seems no reason 
why he should not visit women already confined, in whom he has not 
to make vaginal examinations. 

Nature of the Septic Poison. — As to the precise character of the 
septic poison — although of late much has been said about it, and 
there is good reason to believe that further research may throw light 
on this obscure subject — too little is known to justify any positive 
statement. With regard to the influence of the minute organisms 
known as bacteria, and their supposed connection with the produc- 
tion of the disease, this is especially the case. Heiberg has proved 
that they may be traced, in most cases of puerperal septicaemia, pass- 
ing through the veins and lymphatics, and that they are found in 
various organs and pathological products. But what their relation 
is to the disease, whether they themselves form the septic matter, or 



582 PUERPERAL STATE. 

carry it, or whether they are mere accidental concomitants of the 
pysemie process, it is impossible, in the present state of our know- 
ledge, to state ; and I, therefore, prefer to dwell on that part of the 
subject which is of clinical importance, rather than enter into specu- 
lative theories, which may to-morrow prove to be valueless. 

Channels of Diffusion. — Passing on to the channels of diffusion 
through which the septic matter may act, we have to consider its 
effects on the structures with which it is brought into contact, and 
the mode in which it may infect the system at large ; and this will 
include a consideration of the pathological phenomena. 

Local changes consequent on the absorption of the poison are pretty 
constant, and of these we may form an intelligible idea of thinking 
of them as similar in character and causation to those which we have 
the opportunity of studying when septic matter is applied to a wound 
open to observation, as, for example, in cases of blood-poisoning fol- 
lowing a dissection wound. Distinct traces of local action are not of 
invariable occurrence, and in some of the worst class of cases, when 
the amount of septic matter is great, and its absorption rapid, death 
may occur after an illness of short duration bat great intensity, and 
before appreciable local changes, either at the site of absorption or 
in the system at large, have had time to develop themselves. The 
fact that puerperal fever may prove fatal, without leaving any tan- 
gible post-mortem signs, has often been pointed out, such cases most 
frequently occurring during the endemic prevalence of the disease in 
lying-in hospitals. There can be little doubt, however, that in such 
cases of intense septicaemia marked pathological changes exist, in the 
form of alterations of the blood and degenerations of tissue, but not 
of a character which can be detected by an ordinary post-mortem 
examination. In the great majority of cases, indications of the dis- 
ease exist at the site of absorption. These are described by patholo- 
gists as identical in their character with the inflammatory oedema 
which occurs in connection with phlegmonous erysipelas. If lacera- 
tions exist in the cervix or vagina they take on unhealthy action, 
their edges swell, and their surfaces become covered with a yellowish 
coat, similar in appearance to diphtheritic membrane. The mucous 
membrane of the uterus is also generally found to be affected, and 
in a degree varying with the intensity of the local septic process. 
There is evidence of severe endometritis ; and, very frequently, the 
whole lining of the uterus is profoundly altered, softened, covered 
with patches of diphtheritic deposit, and it may be in a state of 
general necrosis. In the severer cases these changes affect the mus- 
cular tissue of the uterus, which is found to be swollen, soft, imper- 
fectly contracted, and even partially necrosed, a condition which is 
likened by Heiberg to hospital gangrene. The connective tissue 
surrounding the generative tract is also swollen and cedematous, and 
the inflammation may in this w r ay reach the peritoneum, although 
peritonitis, so often observed in puerperal septicaemia, does not ne- 
cessarily depend on the direct transmission of inflammation from the 
pelvic connective tissue, but is more often a secondary phenomenon. 

The channels through which general systemic infection may super- 



PUERPERAL SEPTICEMIA. 583 

vene are the lymphatics and the venous sinuses, the former being by 
far the most important. Eecent researches have shown the great 
number and complexity of the lymphatics in connection with the 
pelvic viscera, and marked traces of the absorption of septic matter 
are almost always to be found, except in those very intense cases 
alreadj^ alluded to, in which no appreciable post-mortem signs are 
discoverable. The septic matter is probably absorbed from the 
lymph spaces abounding in the connective tissue, and carried along 
the lymphatic canals to the nearest glands. The result is inflamma- 
tion of their coats, and thrombosis of their contents, which may be 
seen on section as a creamy purulent substance. The absorption of 
septic material may, as Virchow has shown, be delayed by the local 
changes produced in the lymphatics and in the glands with which 
they communicate, which are, therefore, conservative in their action ; 
and the further progress of the case may in this way be stopped, and 
local inflammation alone result, such cases being believed by Heiberg 
to be examples of abortive pyaemia. On the other hand the free 
septic material may be too abundant and intense to be so arrested, 
it may pass on through the lymph canals and glands, until it reaches 
the blood current through the thoracic duct, and so produces a gene- 
ral blood-infection. This mode of absorption of septic matter, and 
the tendency of the glands to arrest its further progress, serve to 
explain the progressive character of many cases, in which fresh 
exacerbations seem to occur from time to time; since fresh quantities 
of poison, generated at its source of origin, may be absorbed as the 
case progresses. The uterine veins are supposed by D'Espinne to be 
the channel of absorption in the intense form of disease which proves 
fatal very shortly after delivery, too soon for the more gradual pro- 
cess of lymphatic absorption to have become established. It is evi- 
dent that the veins are not likely to act in this way, since they must, 
under ordinary circumstances, be completely occluded by thrombi, 
otherwise hemorrhage would occur. If, however, uterine contraction 
be incomplete, the occlusion of the venous sinuses may be imperfect, 
and absorption of septic material through them may then take place. 
Some writers have laid great stress on imperfect uterine contraction 
in predisposing to septicaemia, and its influence may thus be well 
explained. The veins may bear an important part in the production 
of septicaemia, independent of the direct absorption of septic matter 
through them, by means of the detachment of minute portions of 
their occluding thrombi, in the form of emboli. If phlegmonous 
inflammation occur in the immediate vicinity of the veins, the 
thrombi they contain may become infected. When once blood 
infection has occurred, by any of these channels, general septicaemia, 
the so-called puerperal fever, is developed. 

Pathological Phenomena observed after general Blood-infection. — 
The variety of pathological phenomena found on post-mortem ex- 
amination has had much to do with the prevalent confusion as to the 
nature of the disease. This has resulted in the description of many 
distinct forms of puerperal fever; the most marked pathological alte- 
ration having been taken to be the essential element of the disease. 



584 PUERPERAL STATE. 

As a matter of fact there is no doubt that various types of pathologi- 
cal change are met with. Heiberg describes four chief classes which 
are by no means distinctly separated from one another, are often 
found simultaneously in the same subject, and are certainly not to be 
distinguished by the symptoms during life. 

Intense Cases without marked Post-mortem Signs. — Of these, the 
first is the class of cases in which no appreciable morbid phenomena 
are found after death. This formidable and fatal form of the disease 
has long been well known, and is that described by some of our 
authors as adynamic, or malignant puerperal fever. It is the variety 
which was so prevalent in our lying-in hospitals, and which Eams- 
botham talks of as being second only to cholera in the severity and 
suddenness of its onset, and in the rapidity with which it carried off 
its victims. It is quite erroneous to suppose that the existence of 
pathological changes in this form of disease has never been recog- 
nized. Even with the coarse methods of examination formerly used, 
the occurrence of a fluid and altered state of the blood, and ecchy- 
moses in connection with various organs — especially the lungs, spleen, 
and kidneys — were noticed and specially described by Copland in 
his dictionary of medicine. More recently it has been clearly proved 
by the microscope that there exist, in addition, the commencement 
of inflammation in most of the tissues, as shown by cloudy swellings, 
and granular infiltration and disintegration of the cell elements; 
proving that the blood, heavily charged with septic matter, had set 
up morbid action wherever it circulated, the patient succumbing 
before this had time to develop. 

Cases Characterized by Inflammation of the Serous Membranes. — 
In the second type, and that perhaps most commonly met with, the 
morbid changes are most frequently found in the serous membranes, 
in the pleura, the pericardium, but, above all, in the peritoneum, the 
alterations in which have long attracted notice, and have been taken 
by many writers as proving peritonitis to be the main element of the 
disease. Evidences of more or less peritonitis are very general. In 
the more severe cases there is little or no exudation of plastic lymph, 
such as is found in peritonitis unassociated with septicaemia. There 
is a greater or less quantity of brownish serum only, the coils of 
intestine, distended with flatus, and highly congested, being sur- 
rounded by it. More often there are patchy deposits of fibrinous 
exudation over many of the viscera, the fundus uteri, the under sur- 
face of the liver, and the distended intestines. There is then also a 
considerable quantity of sero- purulent fluid in the abdominal cavity. 
The pleural cavities may also exhibit similar traces of inflammatory 
action, containing imperfectly organized lymph, and sero-purulent 
fluid. Schrceder states that pleurisy is more often the direct result 
of transmission of inflammation through the substance of the dia- 
phragm or lung, than a secondary consequence of the septicaemia. 
In like manner evidences of pericarditis may exist, the surface of the 
pericardium being highly injected, and its cavity containing serous 
fluid. Inflammation of the synovial membranes of the larger joints, 



PUERPERAL SEPTICEMIA. 585 

occasionally ending in suppuration, is not uncommon, and may pro- 
bably be best included under this class of cases. 

Cases Characterized by changes in the Mucous Membrane. — In the 
third type the mucous membranes appear to bear the brunt of the 
disease. The pathological changes are most marked in the mucous 
membrane lining the intestines, which is highly congested and even 
ulcerated in patches, with numerous small spots of blood extra vasat^d 
in the sub-mucous tissue. Similar small apoplectic effusions have 
been observed in the substance of the kidneys, and under the mucous 
membrane of the bladder. Pneumonia is of common occurrence. 
In most cases it is probably secondary to the impaction of minute 
emboli in the smaller branches of the pulmonary artery ; but it may 
doubtless arise from independent inflammation of the lung tissue, 
and will then be included in the class of cases now under considera- 
j tion. 

Cases Characterized by the Impaction of Infected Emboli and Second- 
ary Inflammation and Abscess. — -The fourth ciass of pathological 
phenomena are those which are produced chiefly by the impaction 
of minute infected emboli in small vessels in various parts of the 
ibody. These are the cases which most closely resemble surgical 
(pyaemia, both in their symptoms and post-mortem signs, and which 
by many writers are described under the name of puerperal pyaemia. 
| The dependence of puerperal fever on phlebitis of the uterine veins 
i was a favorite theory, and in a large proportion of cases the coats of 
the veins show signs of inflammation, their canals being occupied 
with thrombi in a more or less advanced state of disintegration. The 
mode in which these thrombi may become infected has been shown 
by Babnoff, who has proved that leucocytes may penetrate the coats 
of the vein, and entering its contained coagulum, may set up disin- 
tegration and suppuration. This observation brings these pyaemic 
forms of disease into close relation with septicaemia, such as we have 
been studying, and justifies the conclusion of Yerneuil that purulent 
infection is not a distinct disease, but only a termination of septi- 
caemia, with which it ought to be studied. We have, moreover; to 
differentiate these results of embolism from those considered in a 
subsequent chapter ; the characteristic of these cases being the in- 
fected nature of the minute emboli. Localized inflammations and 
.abscesses, from the impaction of minute capillary emboli, are found 
in many parts of the body ; most frequently in the lungs, then in 
the kidneys, spleen, and liver, and also in the muscles and connective 
I tissues. Pathologists are by no means agreed as to the invariable 
' dependence of these on embolism, nor is it possible to prove their 
origin from this source by post-mortem examination. Some attri- 
bute all such cases to embolism, others think that they may be the 
results of primary septicaemic inflammation. It has been proved by 
Weber that minute infected emboli may pass through the lung- 
capillaries ; and this disposes of one argument against the embolic 
theory, based on the supposed impossibility of their passage. It is 
probable that both causes may operate, and that localized inflamma- 
tions occurring a short time after delivery are directly produced by 
38 



586 PUERPERAL STATE. 

the infected blood, while those occurring after the lapse of some time, 
as in the second or third week, depend upon embolism. 

Description of the Disease. — From what has been said as to the 
mode of infection in puerperal septicaemia, and as to the very various 
pathological changes which accompany it, it will not be a matter of 
surprise to find that the symptoms are also very various in different 
cases. This can readily be explained by the amount and virulence 
of the poison absorbed, the channels of infection, and the organs 
which are chiefly implicated; but it renders it very difficult to 
describe the disease satisfactorily. 

The symptoms generally show themselves within two or three 
days after delivery. As infection most often occurs during labor, 
or, in cases which are autogenetic, within a short time afterwards, 
and before the lesions of continuity in the generative tract have 
commenced to cicatrize, it can be understood why septicaemia rarely 
commences later than the fourth or fifth day. 

In the great majority of cases the disease begins insidiously. There 
are, generally, some chilliness and rigor, but by no means always, 
and even when present they frequently escape observation, or are 
referred to some transient cause. The first symptom which excites 
attention is a rise in the pulse, which may vary from 100 to 140 or 
more, according to the severity of the attack ; and the thermometer 
will also show that the temperature is raised to 102°, or, in bad 
cases, even to 104° or 106°. Still, it must be borne in mind that 
both the pulse and temperature may be increased in the puerperal 
state from transient causes, and do not, of themselves, justify the 
diagnosis of septicaemia. 

Symptoms of Intense Septicaemia. — In the more intense class of 
cases, in which the whole system seems overwhelmed with the 
severity of the attack, the disease progresses with great rapidity, 
and often without any appreciable indication of local complication. 
The pulse is very rapid, small, and feeble, varying from 120 to 1-10, 
and there is generally a temperature of 108° or 10-i°. There may 
be little or no pain, or there may be slight tenderness on pressure 
over the abdomen or uterus; and, as the disease progresses, the 
intestines get largely distended with flatus, so that intense tympanites 
often form a most distressing symptom. The countenance is sallow, 
sunken, and has a very anxious expression. As a rule, intelligence 
is unimpaired, and this ma}?- be the case even in the worst forms of 
the disease, and up to the period of death. At other times, there is 
a good deal of low muttering delirium, which often occurs at night 
alone, and alternates with intervals of complete consciousness, but 
is occasionally intensified, for a short time, into a more acute form. 
Diarrhoea and vomiting are of very frequent occurrence; by the 
latter dark, grumous, coffee- ground substances are ejected. The 
diarrhoea is occasionally very profuse and uncontrollable; in mild 
cases it seems to relieve the severity of the symptoms. The tongue 
is moist and loaded with sordes ; but sometimes it gets dark and dry, 
especially towards the termination of the disease. The lochia are 
generally suppressed, or altered in character, and sometimes they 
have a highly-offensive odor, especially when the disease is auto- 



PUERPERAL SEPTICEMIA. 587 

genetic. The breathing is hurried and panting, and the breath 
itself has a very characteristic, heavy, sweetish odor. The secretion 
of milk is often, but not always, arrested. 

Duration of the Disease. — \Tith more or less of these symptoms 
the case goes on; and when it ends fatally it generally does so 
within a week, the fatal termination being indicated by more weak- 
ness, rapid, threadlike, or intermittent pulse, marked delirium, great 
tympanites, and sometimes a sudden fall of temperature, until at last 
the patient sinks with all the symptoms of profound exhaustion. 

Variety of Symptoms in Different Cases. — In milder cases similar 
symptoms, variously modified and combined, are present. It is 
seldom that two precisely similar cases are met with ; in some, the 
rapid, weak pulse is most marked ; in others, abdominal distension, 
vomiting, diarrhoea, or delirium. 

Symptoms of Peritonitis. — Local complications variously modify 
the symptoms and course of the disease. The most common is peri- 
tonitis, so much so that with some authors puerperal fever and puer- 
peral peritonitis are sjmonymous terms. Here the first symptom is 
severe abdominal pain, commencing at the lower part of the abdomen, 
where the uterus is felt enlarged and tender. As the abdominal pain 
and tenderness spread, the sufferings of the patient greatly increase, 
the intestines become enormously distended with flatus, and the 
breathing is entirely thoracic, in consequence of the upward dis- 
placement of the diaphragm and the fact that the abdominal muscles 
are instinctively kept as much in repose as possible. The patient 
lies on her back, with her knees drawn up, and sometimes cannot 
bear the slightest pressure of the bed clothes. There is generally 
much vomiting, and often severe diarrhoea. The temperature gener- 
ally ranges from 102° to 104°, or eA^en 106°, and is subject to occa- 
sional exacerbations and remissions^ possibly depending on fresh 
absorption of septic matter. The case generally lasts for a week or 
more, the symptoms going on from bad to worse, and the patient 
dying exhausted. D'Espinne points out that rigors, with exacerba- 
tions of the general symptoms, not unfrequentty occur about the 
sixth or seventh day, which he attributes to fresh systemic infection, 
from foetid pus in the peritoneal cavity. It must not be supposed 
that all these symptoms are necessarily present when the peritonic 
I complication exists. Pain especially is often entirely absent, and I 
] have seen cases in which post-mortem examination proved the exist- 
ence of peritonitis in a very marked degree, in which pain was 
entirely absent. Sometimes the pain is only slight, and amounts to 
little more than tenderness over the uterus. 

Other local complications are characterized by their own special 
symptoms ; thus pneumonia by dyspnoea, cough, dulness, etc. ; peri- 
carditis by the characteristic rub ; pleurisy by dulness on percussion ; 
kidney affection by albuminuria and the presence of casts; liver 
; complication by jaundice ; and so on. 

Pysemic Forms of the Disease. — The course of the disease is not 
always so intense and rapid, being, in some cases, of a more chronic 
character. The symptoms in the early stage are often indistinguish- 
able from those already described ; and it is generally only after the 



588 PUERPERAL STATE. 

second week, that indications of purulent infection develop them- 
selves. Then we often have recurrent and very severe rigors, with 
marked elevations and remissions of temperature. At the same time 
there is generally an exacerbation of the general symptoms, a pecu- 
liar yellowish discoloration of the skin, and occasionally well- 
developed jaundice. Transient patches of erythema are not uncom- 
monly observed on various parts of the skin, and such eruptions 
have often been mistaken for those of scarlet fever or other zymotic 
disease. Localized inflammations and suppuration may rapidly 
follow. Amongst the most common are inflammation or even sup- 
puration of the joints — the knees, shoulders, or hips — which is pre- 
ceded by difficulty of movement, swelling, and very acute pain. 
Large collections of pus in various parts of the muscles and connec- 
tive tissues are not rare. Suppurative inflammation may also be 
found in connection with many organs, as in the eye, in the pleura, 
pericardium, or lungs ; each of which will, of course, give rise to 
characteristic symptoms, more or less modified by the type of the 
disease and the intensity of the inflammation. 

Treatment. — In considering the all-important subject of treatment, 
the views of the practitioner are naturally biased by the theory he 
has adopted of the nature of the disease. If that here inculcated be 
correct, the indications we have to bear in mind are : 1st, to discover, 
if possible, the source of the poison, in the hope of arresting further 
septic absorption ; 2d, to keep the patient alive until the effects of 
the poison are worn off; and 3d, to treat any local complications that 
may arise. 

The Use of Antiseptic Injections. — The first is likely to be of great 
importance in cases of self-infection as fresh quantities of septic mat- 
ter may be, from time to time, absorbed. We, fortunately, are in 
possession of a powerful means of preventing further absorption by 
the application of antiseptics to the interior of the uterus, and to the 
canal of the vagina. This is especially valuable when the existence 
of decomposing coagula, or other sources of septic matter, is sus- 
pected in the uterine cavity, or when offensive discharges are present. 
Disinfection is readily accomplished by washing out the uterine 
cavity, at least twice daily, by means of a Higginson's syringe with 
a long vaginal pipe attached. 1 The results are sometimes very re- 

1 My colleague, Dr. Hayes, has invented a silver tube for the purpose of adminis- 
tering such intra-uterine injections (Fig. 182), which answers its purpose admirably. 

Fig. 182. 




Hayes's Tube for Intra-uterine Injections. 

The numerous apertures at its extremity allow of a number of minute streams of fluid 
being thrown out in the form of a spray over the interior of the uterus, the complete 



PUERPERAL SEPTICEMIA 



589 



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■markable, the threatening symptoms rapidly disappearing, and the 
^temperature and pulse falling so soon after the use of the antiseptic 
■injections as to leave no doubt of the 
beneficial effects of the treatment. 
I cannot better illustrate the advan- 
tages of this treatment than by the 
^accompanying temperature chart, 
•which is from a case which came 
junder my observation in the out-door 
Ipractice of King's College Hospital, 
lit was that of a healthy woman, 
thirty-six years of age, who had an 
easy and natural labor. Nothing re- 
markable was observed until the 3d 
day after delivery, when the temper- 
ature was found to be slightly in- 
creased. On the morning of the 8th day the temperature had risen 
to 105.4°. She was delirious, with a rapid, thready pulse, clammy 
perspiration, tympanitic abdomen, and her general condition indicated 
the most urgent clanger. On vaginal examination a piece of com- 
pressed and putrid placenta was found in the os. This was removed 
by my colleague, Dr. Hayes, and the uterus thoroughly washed out 
with Condy's fluid and water. The same evening the temperature 
had sunk to 99°, and the general symptoms were much improved. 
The next day there was a slight return of offensive discharge, and 
an aggravation of the symptoms. After again washing out the 
uterus the temperature fell, and from that elate the patient convalesced 
without a single bad symptom. 

This is a very well-marked example of the value of local anti- 
septic treatment, and I have seen many cases of the same kind. It 
should, therefore, never be omitted in all cases in which self-infection 
is possible; and, indeed, even when there is no reason to suspect the 
presence of a local focus of infection, the use of antiseptic lotions is 
advisable, as a matter of precaution, since it can do no harm, and is 
generally comforting to the patient. Any antiseptic may be used, 
such as a weak solution of carbolic acid, or of tincture of iodine, or 
Condy's fluid largely diluted. I generally use the two latter alter 
nately, the one in the morning, the other in the evening. The nozzle 
of the syringe should be guided well through the cervix, and the 
cavity of the uterus thoroughly washed out, until the fluid that 
issues from the vagina is no longer discolored. As the os is always 
patulous, there is no risk of producing the troublesome symptoms 
of uterine colic which occasionally follow the use of intra-uterine 
injections in the unimpregnated state. It is quite useless to entrust 
the injection to the nurse, and it should be performed at least twice 
daily by the practitioner himself, in all cases in which the discharges 
are offensive. 



bathing of its surface and washing out of its cavity being thus insured. It is, more- 
over, introduced more easily than the ordinary vaginal pipe, and can be attached to 
a Higginson syringe. 



590 THE PUERPERAL STATE. 

Administration of Food and Stimulants. — In a disease characterized 
by so marked a tendency to prostration, the importance of sustaining 
the vital powers by an abundance of easily assimilated nourishment 
cannot be overrated. Strong beef-tea, or other forms of animal soup, 
milk, alone or mixed either with lime or soda water, and the yolk of 
eggs, beat up with milk and brandy, should be given at short inter- 
vals, and in as large quantities as the patient can be induced to take; 
and the value of thoroughly efficient nursing will be specially ap- 
parent in the management of this important part of the treatment. 
As there is frequently a tendency to nausea, the patient may resist 
the administration of food, and the resources of the practitioner will 
be taxed in administering it in such form and variety as will prove 
least distasteful. Generally speaking, not more than one or two 
hours should be allowed to elapse without some nutriment being 
given. The amount of stimulant required will vary with the inten- 
sity of the symptoms, and the indications of debility. Generally, 
stimulants are well borne, prove decidedly beneficial, and require to 
be given pretty freely. In cases of moderate severity a tablespoonful 
of good old brandy or whiskey every four hours may suffice; but 
when the pulse is very rapid and thready, when there is much low 
delirium, tympanites, or sweating (indicating profound exhaustion), 
it may be advisable to give them in much larger quantities and at 
shorter intervals. The careful practitioner will closely watch the 
effects produced, and regulate the amount by the state of the patient, 
rather than by any fixed rule ; but in severe cases, eight or twelve 
ounces of brandy, or even more, in the twenty-four hours may be 
given with decided benefit. 

Venesection not Admissible. — Venesection, both general and local, 
was long considered a sheet anchor in this disease. Modern views 
are, however, entirely opposed to its use; and in a disease character- 
ized by so profound an alteration of the blood, and so much prostra- 
tion, it is too dangerous a remedy to employ, although it is possible 
that it might alleviate temporarily the severity of some of the 
symptoms, especially in cases in which peritonitis is well marked, 
and much local pain and tenderness are present. 

Medicinal Treatment. — The rational indications in medicinal treat- 
ment are to lessen the force of the circulation as much as is possible 
without favoring exhaustion; and to diminish the temperature. 

Use of Arterial Sedatives. — For the former purpose, Barker strongly 
advocates the use of veratrum viride, in doses of five drops of the 
tincture every hour, until the pulse falls to below 100, when its 
effects are subsequently kept up by two or three drops every second 
hour. Of this drug I have no personal experience; but I have ex- 
tensively used minute doses of tincture of aconite for the same pur- 
pose, and, when carefully given, I believe it to be a most valuable 
remedy. The way I have administered it is to give a single drop of 
the tincture, at first every half-hour, increasing the interval of ad- 
ministration according to the effect produced. Generally, after giving 
four or five doses at intervals of half an hour, the pulse begins to 
fall, and afterwards a few doses, at intervals of one or two hours, 



PUERPERAL SEPTICEMIA. 591 

Will suffice to prevent the heart's action rising to its former rapidity. 
The advantage of thus modifying cardiac action, with the view of 
preventing excessive waste of tissue, cannot be questioned. It is 
evident that so powerful a remedy must not be used without the 
most careful supervision, for, if continued too long, or given at too 
frequent intervals, it may undnly depress the circulation, and do 
more harm than good. It is necessary, therefore, that the practi- 
tioner should constantly watch the effect of the drug, and stop it if 
the pulse become very weak, or if it intermit. It is most likely to 
be useful at an early stage of the disease before much exhaustion is 
present, and then only when the pulse is of a certain force and 
volume. Barker says of the veratrum viride, what is also true of 
aconite, that "it should not be given in those cases in which rapid 
prostration is manifested by a feeble, thread-like irregular pulse, 

I profuse sweats, and cold extremities." 

Reduction of Temperature. — The reduction of temperature must 

, form an important part of our treatment, and for this purpose many 
agents are at our disposal. 

Quinine in large doses, of from 10 to 20 grains, has been much 

j used for this purpose, especially in Germany. After its exhibition 

I the temperature frequently falls one or two degrees. It may be given 
morning and evening. Unpleasant head-symptoms, deafness, and 
ringing in the ears, often render its continuance for a length of time 
impossible; these may, however, be much lessened by the addition 
of 10 to 15 minims of hydrobromic acid to each dose. 

Salicylic acid, in doses of from 10 to 20 grains, or the salicylate of 
soda in the same doses, is a valuable antipyretic, which I have found 
on the whole more manageable than quinine. Under its use the 
temperature often falls considerably in a short space of time. It is, 
however, apt to depress the circulation, and thus requires to be care- 
fully watched while it is being administered, and should the pulse 
become very small and feeble, it should be discontinued. 

Warburg's Tincture. — In some cases, especially when the fever has 
assumed a remittent type, I have administered with marked benefit, 
a drug which is of high repute in India, in the worst class of mala- 
rious remittent fevers, and the almost marvellous effects of which in 
such cases I had myself witnessed in India many years ago. This is 
the so-called Warburg's tincture, the value of which has been testified 
to by many high authorities ; among whom I may mention Dr. Mac- 
lean of Ketley, Dr. Broadbent, and Sir Alexander Armstrong, the 
Director-General of the Medical Department of the Navy, who informs 
me that it is now supplied to all Her Majesty's ships in the tropics, 
because it is found to be of the utmost value in cases in which quinine 
has little or no effect. 

Eecently its composition has been made public by Dr. Maclean. 
The basis is quinine, in combination with various aromatics and bit- 
ters, some of which probably intensify its action. Be this as it may, 
the testimony in favor of the anti-pyretic action of the remedy is 
very strong. I have found its exhibition followed by a profuse dia- 
phoresis (this being its almost invariable effect), and sometimes a 



592 THE PUERPERAL STATE. 

rapid amelioration of the symptoms. In other cases in which I have 
tried it, like every thing else, it has proved of no avail. 

Application of Cold. — Cold may be advantageously tried in suitable 
cases. The simplest mode of using it is by Thornton's ice-cap, by 
which a current of cold water is kept continuously running round 
the head. This has been found of great value in pyrexia after ova- 
riotomy, and I have also found it useful as a means of reducing tem- 
perature in puerperal cases. It is a comforting application, and gives 
great relief to the throbbing headache, which often causes much suf- 
fering. Under its use the temperature often falls two or more de- 
grees, and it is easily continued day or night. 

In very serious cases, when the temperature reaches 105° and up- 
wards, the external application of cold to the rest of the body may 
be tried. I have elsewhere related a case of puerperal septicaemia 
with hyper-pyrexia, the temperature continuously ranging over 105°, 
in which I kept the patient for eleven days 1 nearly continuously 
covered with cloths soaked in iced water, by which means only was 
the temperature kept within moderate bounds, and life preserved. 
But this method of treatment is excessively troublesome, and is in 
no way curative. It is only of use in moderating the temperature 
when it has reached a point at which it could not continue long with- 
out destroying the patient. I should, therefore, never think of em- 
ploying it unless the temperature was over 105°, and then only as a 
temporary expedient, requiring incessant watching, to be desisted 
from as soon as the temperature had reached a more moderate height. 
It is clearly impossible to place a puerperal patient in a bath, as is 
practised in hyper-pyrexia associated with acute rheumatism. The 
same effect may, however, be obtained by placing her on Mackintosh 
sheeting, and covering the body with towels soaked in iced water, 
which are frequently renewed by the attendant nurses. During the 
application the temperature should be constantly taken, and as soon 
as it has fallen to 101°, the cold applications should be discontinued. 

Administration of Turpentine. — Amongst other remedies which 
have been used is turpentine, which was highly thought of by the 
Dublin school. In cases with much tympanitic distension, and a 
small weak pulse, it is sometimes of unquestionable value, and it 
probably acts as a strong nervine stimulant. Given in doses of 15 
to 20 minims, rubbed up with mucilage, it can generally be taken in 
spite of its nauseous taste. 

Evacuant Remedies. — Purgatives, diaphoretics, or even emetics, 
have often been employed as eliminants of the poison. The former 
are strongly recommended by Schroeder and other German authori- 
ties, and in this country they were formerly amongst the most 
favorite remedies. In the first volume of the " Obstetrical Journal," 
there is a paper by Mr. Morton, in which this practice is strongly 
advocated, and some interesting cases are recorded in which it appa- 
rently acted well. He administers calomel in doses of 3 or 4 grains 

1 A Lecture on a case of Puerperal Septicemia, with Hyper-pyrexia, treated by 
the continuous application of Cold. — Brit. Med. Journ., Nov. 17, 1877. 



PUERPERAL SEPTICEMIA. 593 

with compound extract of colocynth, so as to keep up a free action 
of the bowels. It seems quite reasonable, when there is constipation, 
to promote a gentle action of the bowels by some mild aperient ; but, 
bearing in mind that severe and exhausting diarrhoea is a common 
accompaniment of the disease, I should myself hesitate to run the risk 
of inducing it artificially, especially as there is no proof whatever that 
septic matter can really be eliminated in this way. At the commence- 
ment of the disease, however, I have often given one or two aperient 
doses of calomel with decided benefit. 

Internal Antiseptic Remedies. — It is possible that further research 
will give us some means of counteracting the septic state of the blood, 
and the sulphites and carbolates have been given for this purpose, 
but as yet with no reliable results. 

Tincture of Perchloride of Iron. — The tincture of the perchloride 
of iron naturally suggests itself, from its well-known effects in surgi- 
cal pyaemia. In the less intense forms of the disease, especially when 
; local suppurations exist, it is certainly useful, and may be given in 
doses of 10 to 20 minims every 3 or i hours. In very acute cases 
other remedies are more reliable, and the iron has the disadvantage 
I of not unfrequently causing nausea or vomiting. 

Opiates. — When restlessness, irritation, and want of sleep are 
prominent symptoms, sedatives may be required. Under such cir- 
cumstances opiates may be given at night, and Battley's solution, 
nepenthe, or the hypodermic injection of morphia, are the forms 
which answer best. 

Treatment of Local Complications. — Pain and tenderness, and local 
complications, must be treated on general principles. The distress 
from them is most experienced when peritonitis is well marked. 
Then warm and moist applications, in the form of poultices or fomen- 
tations, are very useful. Eelief is also sometimes obtained from 
turpentine stupes, and, when the tympanites is distressing, turpentine 
enemata are very serviceable. I have found the free application 
over the abdomen of the flexible collodium of the pharmacopoea 
decidedly useful in alleviating the suffering from peritonitis. 

Such are the remedies most used in the treatment of this disease. 
It is needless to say that it is quite impossible to lay down fixed rules 
for the management of any individual case ; and it is obvious that, 
if puerperal septicaemia be not a special and distinct disease, its judi- 
cious management must depend on the general knowledge of the 
attendant, and on a careful study of the symptoms each separate case 
presents. 



594 THE PUERPERAL STATE, 



CHAPTEK VI. 

PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 

Under the head of thrombosis we may class several important 
diseases connected with the puerperal state, which have received far 
less attention than they deserve. It is only of late years that some, we 
may probably safely say the majority, of those terribly sudden deaths 
which from time to time occur after delivery, have been traced to 
their true cause, viz., obstruction of the right side of the heart and 
pulmonary arteries from a blood- clot, either carried from a distance, 
or, as I shall hope to show, formed in situ. Although the result, 
and, to a great extent, the symptoms, are identical in both, still a 
careful consideration of the history of these two classes of cases tends 
to show that in their causation they are distinct, and that they ought 
not to be confounded. In the former, we have primarily a clotting 
of blood in some part of the peripheral venous system, and the sepa- 
ration of a portion of such a thrombus due to changes undergone 
during retrograde metamorphosis tending to its eventual absorption. 
In the latter we have a local deposition of fi brine, the result of blood 
changes consequent on pregnancy and the puerperal state. The 
formation of such a coagulum in vessels, the complete obstruction 
of which is incompatible with life, explains the fatal results. "When, 
however, a coagulum chances to be formed in more distant parts of 
the circulation, the vital functions are not immediately interfered 
with, and we have other phenomena occurring, due to the obstruction. 
The disease known as phlegmasia dolens, I shall presently attempt 
to show, is one result of blood-clot forming in peripheral vessels. 
But from the evident and tangible symptoms it produces it has long 
been considered an essential and special disease, and the general 
blood dyscrasia which produces it, as well as other allied states, has 
not been studied separately. I shall hope to show that all these 
various, conditions, dissimilar as they at first sight appear, are very 
closely connected, and that they are in fact due to a common cause; 
and thus, I think, we shall arrive at a clearer and more correct idea 
of their true nature, than if we looked upon them as distinct and 
separate affections, as has been commonly clone. I am aware that 
in phlegmasia dolens, the pathology of which, has received perhaps 
more study than that of almost any other puerperal affection, some- 
thing beyond simple obstruction of the venous system of the affected 
limb is probably required to account for the peculiar tense and 
shining swelling which is so characteristic. Whether this be an 
obstruction of the lymphatics, as Dr. Tilbury Fox and others have 
maintained with much show of reason, or whether it is some as yet 
undiscovered state, further investigation is required to show. But 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 595 

it is beyond any doubt that the important and essential part of the 
disease is the presence of a thrombus in the vessels; and I think it 
will not be difficult to prove that in its causation and history it is 
precisely similar to the more serious cases in which the pulmonary 
arteries are involved. 

It will be well to commence the study of the subject by a considera- 
tion of the conditions which, in the puerperal state, render the blood 
so peculiarly liable to coagulation, and we may then proceed to discuss 
the symptoms and results of the formation of coagula in various 
parts of the circulatory system. 

Conditions which favor Thrombosis. — The researches of Yirchow, 
Benj. Ball, Humphrey, Eichardson, and others, have rendered us 
tolerably familiar with the conditions which favor the coagulation 
of the blood in the vessels. These are chiefly: 1. A stagnant or 
arrested circulation; as, for example, when the blood coagulates in 
the veins which draw blood from the gluteal region in old and bed- 
ridden people, or as in some forms of pulmonary thrombosis, in 
which the clots in the arteries are probably the result of obstruction 
in the circulation through the lung- capillaries, as in certain cases of 
emphysema, pneumonia, or pulmonary apoplexy. 2. A mechanical 
obstruction around which coagula form, as in certain morbid states 
of the vessels, or, a better example still, secondary coagula which 
form around a travelled embolus impacted in the pulmonary arteries. 
3. And most important of all, in which the coagulation is the result 
of some morbid state of the blood itself. Examples of this last con- 
dition are frequently met with in the course of various diseases, 
such as rheumatism or fever, in which the quantity of flbrine is 
increased, and the blood itself is loaded with morbid material. 
Thrombosis from this cause is of by no means infrequent occurrence 
after severe surgical operations, especially such as have been attended 
with much hemorrhage, or when the patient is in a weak and anaemic 
condition. This has been specially dwelt upon as a not infrequent 
source of death after operation by Fayrer and other surgeons. 1 

Conditions which favor Coagulation in the Puerperal State. — But 
little consideration is required to show why thrombosis plays so im- 
portant a part in the puerperal state, for there most of the causes 
favoring its occurrence are present. Probably there is no other con- 
dition in which they exist in so marked a degree, or are so frequently 
combined. The blood contains an excess of fiorine, which largely 
increases in the latter months of utero- gestation, until, as has been 
pointed out by Andral and Gavarret, it not ^infrequently contains a 
third more than the average amount present in the non-pregnant 
state. As soon as delivery is completed, other causes of blood dys- 
crasia come into operation. Involution of the largely hypertrophied 
uterus commences, and the blood is charged with a quantity of effete 
material, which must be present, in greater or less amount, until 
that process is completed. It is an old observation that phlegmasia 
dolens is of very common occurrence in patients who have lost much 

1 Edin. Med. Journ., March, 1861; Indian Annals of Med., July, 1867. 



596 THE PUERPEKAL STATE. 

blood during labor ; thus Dr. Leishman says: "In no class of cases 
has it been so frequently observed as in women whose strength has 
been reduced to a low ebb by hemorrhage either during or after 
labor; and this, no doubt, accounts for the observation made by 
Merriman, that it is relatively a common occurrence after placenta 
prsevia. 1 An examination of the cases in which death results from 
pulmonary thrombosis shows the same facts, as in a large proportion 
of them severe post-partum hemorrhage has occurred. The exhaus- 
tion following the excessive losses so common after labor must of 
itself strongly predispose to thrombosis, and, indeed, loss of blood 
has been distinctly pointed out by Richardson to be one of its most 
common antecedents. "There is," he observes, "a condition which 
has been long known to favor coagulation and fibrinous deposition. 
I mean loss of blood, and syncope or exhaustion during impoverished 
states of the body." 

Since then so many of the predisposing causes of thrombosis are 
present in the puerperal state, it is hardly a matter of astonishment 
that it should be of frequent occurrence, or that it should lead to 
conditions of serious gravity. And yet the attention of the profession 
has been for the most part limited to a study of one only of the 
results of this tendency to blood-clotting after delivery, no doubt 
because of its comparative frequency and evident symptoms. True 
the balance of professional opinion has lately held that phlegmasia 
dolens is chiefly the result of some morbid condition of the blood 
producing plugging of the veins ; but the wider view which I am 
attempting to maintain, which would bring this disease into close 
relation with the more rarely observed, but infinitely important, 
obstructions of the pulmonary arteries, has scarcely, if at ail, been 
insisted on. Doubtless further investigation will show that it is not 
in these parts of the venous system alone that puerperal thrombosis 
occurs ; but the symptoms and effects of venous obstruction else- 
where, important though they may be, are unknown. 

I propose then to describe the symptoms and pathology of blood- 
clot in the right side of the heart and pulmonary artery. It may 
be useful here to repeat that this is essentially distinct from embo- 
lism of the same parts. The latter is obstruction due to the impac- 
tion of a separated portion of a thrombus formed elsewhere, and for 
its production it is essential that thrombosis should have preceded it. 
Embolism is in fact an accident of thrombosis, not a primary affec- 
tion. The condition we are now discussing I hold to be primary, 
precisely similar in its causation to the venous obstruction which, in 
other situations, gives rise to phlegmasia dolens. 

At the threshold of this inquiry we have to meet the objection, 
started by several who have written on this subject, 2 that sponta- 
neous coagulation of the blood, in the right side of the heart and 
pulmonary arteries, is a mechanical and physiological impossibility. 
This was the view of Virchow, who, with his followers, maintained 

1 Leishman, System of Obstetrics, p. 710. 

2 See especially Bertin, Des Embolics, p. 46 et seq. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 597 

that whenever death from pulmonary obstruction occurred, an em- 
bolus was of necessity the starting-point of the malady, and the 
nucleus round which secondary deposition of fibrine took place. 
Yirchow holds that the primary factor in thrombosis is a stagnant 
state of the blood, and that the impulse imparted to the blood by the 
right ventricle is of itself sufficient to prevent coagulation. It is to 
be observed that these objections are purely theoretical. Without 
denying that there is considerable force in the arguments adduced, I 
think that the clinical history of these cases strongly favors the view 
of spontaneous coagulation ; and I would apply to the theoretical 
objections advanced the argument used by one of their strongest 
upholders, with regard to another disputed point, " Je prefere laisser 
la parole aux faits, car devant eux la theurie s'incline." 1 

The anatomical arrangement of the pulmonary arteries shows how 
spontaneous coagulation may be favored in them ; for, as Dr. Hum- 
phrey has pointed out, 2 "the artery breaks up at once into a number 
of branches, which radiate from it, at different angles, to the several 
parts of the lungs. Consequently, a large extent of surface is pre- 
sented to the blood, and there are numerous angular projections into 
the currents ; both which conditions are calculated to induce the 
spontaneous coagulation of the fibrine." We know also, that throm- 
bosis generally occurs in patients of feeble constitution, often debili- 
tated by hemorrhage, in whom the action of the heart is much weak- 
ened. These facts, of themselves, go far to meet the objections of 
those who deny the possibility of spontaneous coagulation at the roots 
of the pulmonary arteries. 

Results of Post-mortem Examinations. — The records of post-mortem 
examinations show also, that in many of the cases the right side of 
the heart, as well as the larger branches of the pulmonary arteries, 
contained firm, leathery, decolorized, and laminated coagula, which 
could not have been recently formed. The advocates of the purely 
embolic theory maintain that these are secondary coagula, formed 
around an embolus. But surely the mechanical causes which are 
sufficient to prevent spontaneous deposition of fibrine, would also 
suffice to prevent its gathering round an embolus; unless, indeed, the 
obstruction was sufficient to arrest the circulation altogether, when 
death would occur before there was any time for secondary deposit. 
Before we can admit the possibility of embolism we must have at 
least one factor, that is, thrombosis in a peripheral vessel, from which 
an embolus can come. In many of the recorded cases nothing of 
the kind was found, and although, as is argued, this may have 
been overlooked, yet such an oversight can hardly always have been 
made. 

The strongest argument, however, in favor of the spontaneous 
origin of pulmonary thrombosis is one which I originally pointed 
out in a series of papers " On thrombosis and embolism of the pul- 
monary artery as a cause of death in the puerperal state." 3 I there 

1 Bcrtin, Des Embolies, p. 149. 

2 Humphrey, On the Coagulation of the Blood in the Venous System during Life. 

3 Lancet, 1867. 



598 THE PUERPERAL STATE. 

showed, from a careful analysis of 25 cases of sudden death after 
delivery in which accurate post-mortem examination had been made, 
that cases of spontaneous thrombosis and embolism may be divided 
from each other by a clear line of demarcation, depending on the 
period after delivery at which the fatal result occurs. In 7 out of 
these cases there was distinct evidence of embolism, and in them 
death occurred at a remote period after delivery ; in none before the 
nineteenth day. This contrasts remarkably with the cases in which 
the post-mortem examination afforded no evidence of embolism. 
These amounted to 15 out of the 25, and in all of them, with one 
exception, death occurred before the fourteenth day, often on the 
second or third. The reason of this seems to be that in the former, 
time is required to admit of degenerative changes taking place in the 
deposited fibrine leading to separation of an embolus ; while in the 
latter, the thrombosis corresponds in time, and to a great extent no 
doubt also in cause, to the original peripheral thrombosis from which, 
in the former, the embolus was derived. Many cases I have since 
collected illustrate the same rule in a very curious and instructive 
way. 

Another clinical fact I have observed points to the same conclusion. 
In one or two cases distinct signs of pulmonary obstruction have 
shown themselves without proving immediately fatal, and shortly 
afterwards, peripheral thrombosis, as evidenced by phlegmasia dolens 
of one extremity, has commenced. Here the peripheral thrombosis 
obviously followed the central, both being produced by identical 
causes, and the order of events, necessary to uphold the purely em- 
bolic theory, was reversed. 

I hold, then, that those who deny the possibility of spontaneous 
coagulation in the heart and pulmonary arteries do so on insufficient 
grounds, and that we may consider it to be an occurrence, rare no 
doubt, but still sufficiently often met with, and certainly of sufficient 
importance, to merit very careful study. 

History, — Dr. Chas. D. Meigs, of Philadelphia, was one of the first to 
direct attention to spontaneous coagulation of the blood in the right 
side of the heart and pulmonary arteries, as a cause of sudden death 
in the puerperal state. The occurrence itself, however, has been 
carefully studied by Paget, whose paper was published in 1845, four 
years before Meigs wrote on the subject. 1 It is true that none of 
Paget's cases happened after delivery, but he none the less clearly 
apprehended the nature of the obstruction. In 1865, Hecker 2 at- 
tributed the majority of these cases to embolism proper; and since 
that date most authors have taken the same view, believing that 
spontaneous coagulation only occurs in exceptional cases, such as 
those in which, on account of some obstruction in the lung or in the 
debility of the last few hours before death, coagula form in the 
smaller ramifications of the pulmonary arteries, and gradually creep 
backwards towards the heart. 

1 Medico-Chir. Trans., vol. xxvii. p. 162, and vol. xxviii. p. 352; Philadelphia 
Medical Examiner, 1849. 

2 Deutsche Klinicke, 1855. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 599 

Symptoms of Pulmonary Obstruction. — The symptoms can hardly 
be mistaken, and there seems to be no essential difference between 
the symptomatology of spontaneous and embolic obstruction, so that 
the same description will suffice for both. In a large proportion of 
cases the attack comes on with an appalling suddenness which forms 
one of its most striking characteristics. Nothing in the condition of 
the patient need have given rise to the least suspicion of impending 
mischief, when, all at once, an intense and horrible dyspnoea comes 
on ; she gasps and struggles for breath ; tears off the coverings from 
her chest in a vain endeavor to get more air ; and, often, dies in a 
few minutes, long before medical aid can be had, with all the symp- 
toms of asphyxia. The muscles of the face and thorax are violently 
agitated in the attempt to oxygenate the blood, and an appearance 
closely resembling an epileptic convulsion may be presented. The 
face may be either pale or deeply cyanosed. Thus in one case I have 
elsewhere recorded, which was an undoubted example of true em- 
bolism, Mr. Pedler, the resident accoucheur at King's College Hos- 
pital, who was present during the attack, writes of the patient, 1 
"She was suffering from extreme dyspnoea, the countenance was 
excessively pale, her lips white, the face generally expressing deep 

1 anxiety." In another, which was probably an example of sponta- 
neous thrombosis, 2 occurring on the twelfth day after delivery, it is 
stated " the face had assumed a livid purple hue, which was so re- 
markable as to attract the attention both of the nurse and of her 
mother, who was with her." The extreme embarrassment of the cir- 

' culation is shown by the tumultuous and irregular action of the heart, 
in its endeavor to send the venous blood through the obstructed 
arteries. Soon it gets exhausted, as shown by its feeble and flutter-. 
ing beat. The pulse is thread-like, and nearly imperceptible, the 
respirations short and hurried, but air may be heard entering the 
lungs freely. The intelligence during the struggle is unimpaired ; 
and the dreadful consciousness of impending death adds not a little 
to the patient's sufferings, and to the terror of the scene. Such is an 
imperfect account of the symptoms, gathered from a record of what 
has been observed in fatal cases. It will be readily understood why, 
in the presence of so sudden and awful an attack, symptoms have not 
been recorded with the accuracy of ordinary clinical observation. 

A question of great practical interest, which has been entirely 
overlooked by writers on the subject is — Have we any ground for 
supposing that there is a possibility of recovery after svmptoms of 
pulmonary obstruction have developed themselves? That such a 
result must be of extreme rarity is beyond question ; but I have 
little doubt that in some few cases, entirely inexplicable on any other 
hypothesis, life is prolonged until the coagulum is absorbed, and the 
pulmonary circulation restored. In order to admit of this it is, of 
course, essential that the obstruction be not sufficient to prevent the 
passage of a certain quantity of blood to the lungs, to carry on the 
vital functions. The history of many cases tends to show that the 

1 Brit. Med. Journ., March 27, 1869. 2 Obst. Trans., vol. xii. p. 194. 



600 THE PUERPERAL STATE. 

obstructing clot was present for a considerable time before death, and 
that it was only when some sudden exertion was made, such as rising 
from bed or the like, calling for an increased supply of blood which 
could not pass through the occluded arteries, that fatal symptoms 
manifested themselves. This was long ago pointed out by Paget, 1 
who says, " The case proves that, in certain circumstances, a great 
part of the pulmonary circulation may be arrested in the course of a 
week (or a few days more or less), without immediate danger to life, 
or any indication of what had happened." And, after referring to 
some illustrative cases, " Yet in all these cases the characters of the 
clots by which the pulmonary arteries were obstructed, showed 
plainly that they had been a week or more in the process of forma- 
tion." If we admit the possibility of the continuance of life for a 
certain time, we must, I think, also admit the possibility, in a few 
rare cases, of eventful complete recovery. What is required is time 
for the absorption of the clot. In the peripheral venous system 
coagula are constantly removed by absorption. So strong, indeed, 
is the tendency to this, that Humphrey observes with regard to it, 
" It appears that the blood is almost sure to revert to its natural 
channel in process of time." 2 If then the obstruction be only par- 
tial, if sufficient blood pass to keep the patient alive, and a sudden 
supply of oxygenated blood is not demanded by any exertion which 
the embarrassed circulation is unable to meet, it is not inconceivable 
that the patient may live until the obstruction is removed. 

Illustrative Cases. — Such, I believe, to be the only explanation of 
certain cases, some of which, on any other hypothesis, it is impossible 
to understand. The symptoms are precisely those of pulmonary 
obstruction, and the description I have given above may be applied 
to them in every particular; and, after repeated paroxysms, each of 
which seems to threaten immediate dissolution, an eventual recovery 
takes place. "What then, I am entitled to ask, can the condition be, 
if not that which I suggest? As the question I am considering has 
never, so far as I am aware, been treated of by any other writer, I 
may be permitted to state, very briefly, the facts of one or two of 
the cases on which I found my argument, some of which I have 
already published in detail elsewhere. 

K. H., delicate young lady. Labor easy. First child. Profuse postpartum 
hemorrhage. Did well until the 7th day, during the whole of which she felt weak. 
Same day an alarming attack of dyspnoea came on. For several days she remained 
in a very critical condition, the slightest exertion bringing on the attacks. A slight 
blowing murmur heard for a few days at the base of the heart, and then disappeared. 
For two months patient remained in the same state. As long as she was in the 
recumbent position she felt pretty comfortable; but any attempt at sitting up in bed, 
or any unusual exertion, immediately brought on the embarrassed respiration. During 
all this time it was found necessary to administer stimulants profusely to ward off the 
attacks. Eventually the patient recovered completely. 

Q. F., a3t. 44. Mother of twelve children. Confined on July 6. On the 11th 
day she went to bed feeling well. There was no swelling or discomfort of any kind 
about the lower extremities at this time. About half-past 3 A.M. she was sitting up 
in bed, when she was suddenly attacked with an indescribable sense of oppression in 



Op. cit., p. 358. 2 Med. Chir. Trans., vol. xxvii, p. 14. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 601 

the chest, and fell back in a semi-unconscious state, gasping for breath. She re- 
mained in a very critical condition, with the same symptoms of embarrassed respira- 
tion, for three days, when they gradually passed away. Two days after the attack, 
phlegmasia dolens came on, the leg swelled, and remained so for several months. 

This case is an example of the fact I have already referred to, of 
phlegmasia dolens coming on after the symptoms of pulmonary 
obstruction had manifested themselves ; the inference being that 
both depended on similar causes operating on two distinct parts of 
the circulatory sj^stem. 

C. H., aet. 24. Confined of her first child on August 20, 1867. Thirty hours 
after delivery she complained of great weakness and dyspnoea. This was alleviated 
by the treatment employed, but on the ninth day, after making a sudden exertion, 
the dyspnoea returned with increased violence, and continued unabated until I saw 
the patient on September 4, fourteen days after her confinement. The following 
are the notes of her condition made at the time of the visit : "I found her sitting on 
the sofa, propped up with pillows, as she said she could not breathe in the recumbent 
position. The least excitement or talking brought on the most aggravated dyspnoea, 
which was so bad as to threaten almost instant death. Her sufferings during these 
paroxysms were terrible to witness. She panted and struggled for breath, and her 
chest heaved with short gasping respirations. She could not even bear any one to 
stand in front of her, waving them away with her hand, and calling for more air. 
These attacks were very frequent, and were brought on by the most trivial causes. 
She talked in a low suppressed voice, as if she could not spare breath for articulation. 
On auscultation air was found to enter the lungs freely in every direction, both in 
front and behind. Immediately over the site of the pulmonary arteries there was a 
distinct harsh, rasping murmur, confined to a very limited space, and not propagated 
either upwards or downwards. The heart-sounds were feeble and tumultuous." 
These symptoms led me to diagnose pulmonary obstruction, and I, of course, gave 
a most unfavorable prognosis, but to my great surprise the patient slowly recovered. 
I saw her again six weeks later, when her heart-sounds were regular and distinct, 
and the murmur had completely disappeared. 

E. E., a3t. 42, was confined for the first time on November 5, 1873, in the sixth 
month of utero-gestation. She had severe post-partum hemorrhage, depending on 
partially adherent placenta, which was removed artificially. She did perfectly well 
until the 14th day after delivery, when she was suddenly attacked with intense 
dyspnoea, aggravated in paroxysms. Pulse pretty full, 130, but distinctly inter- 
mittent. Air entered lungs freely. The heart's action was fluttering and irregular, 
and, at the juncture of the fourth and fifth ribs with the sternum, there was a loud 
blowing systolic murmur. This was certainly non-existent before, as the heart had 
been carefully auscultated before administering chloroform during labor. For two 
days the patient remained in the same state, her death being almost momentarily 
expected. On the 21st, that is two days after the appearance of the chest symptoms, 
phlegmasia dolens of a severe kind developed itself in the right thigh and leg. She 
continued in the same state for many days, lying more or less tranquilly, but having 
paroxysms of the most intense apnoea, varying from two to six or eight in the twenty- 
four hours. No one who saw her in one of these could have expected her to live 
through it. Shortly after the first appearance of the paroxysms it was observed that 
the cellular tissue of the neck and part of the face became swollen and (Edematous, 
giving an appearance not unlike that of phlegmasia dolens. The attacks were always 
relieved by stimulants. These she incessantly called for, declaring that she felt they 
kept her alive. During all this time the mind was clear and collected. The pulse 
varied from 110 to 130. Respirations about GO, temperature 101° to 102.5°. By 
slow degrees the patient seemed to be rallying. The paroxysms diminished in num- 
ber, and after December 1 she never had another, and the breathing became free 
and easy. The pulse fell to 80, and the cardiac murmur entirely disappeared. The 
patient remained, however, very weak and feeble, and the debility seemed to increase. 
Towards the second week in December she became delirious, and died, apparently 
exhausted, without any fresh chest symptoms, on the 19th of that month. No post- 
mortem examination was allowed. 
39 



602 THE PUERPERAL STATE. 

I have narrated this case, although it terminated fatally, because 
I hold it to be one of the class I am considering. The death was 
certainly not' due to the obstruction, all symptoms of which had 
disappeared, but apparently to exhaustion from the severity of the 
former illness. It illustrates too the simultaneous appearance of 
symptoms of pulmonary obstruction and peripheral thrombosis. 
The swelling of the neck was a curious symptom, which has not 
been recorded in any other cases, and may possibly be a further proof 
of the analogy between this condition and phlegmasia dolens. 

Now, it may, of course, be argued that these cases do not prove 
my thesis, inasmuch as I only assume the presence of a coagulum. 
But I may fairly ask in return what other condition could possibly 
explain the symptoms? They are precisely those which are noticed 
in death from undoubted pulmonary obstruction. No one seeing 
one of them, or even reading an account of the symptoms, while 
ignorant of the result, could hesitate a single instant in the diagnosis. 
Surely, then, the inference is fair that they depended on the same 
cause? In the very nature of things my hypothesis cannot be veri- 
fied by post-mortem examination; but there is at least one case on 
record, in which, after similar symptoms, a clot was actually found. 
The case is related by Dr. Eichardson. 1 It was that of a man who 
for weeks had symptoms precisely similar to those observed in the 
cases I have narrated. In one of his agonizing struggles for breath 
he died, and after death it was found "that a fibrinous band, having 
its hold in the ventricle, extended into the pulmonary artery." This 
observation proves to a certainty that life may continue for weeks 
after the deposition of a coagulum ; and, moreover, this condition 
was precisely what we should anticipate, since, of course, the ob- 
structing coagulum must necessarily be small, otherwise the vital 
functions would be immediately arrested. 

Cardiac Murmurs in Pulmonary Obstruction. — There is a symptom 
noted in two of the above cases, and to less extent in a third, which 
has not been mentioned in any account of fatal cases occurring after 
delivery, viz., a murmur over the site of the pulmonary arteries. 
It is a sign we should naturally expect, and very possibly it would 
be met with in fatal cases if attention were particularly directed to 
the point. In both these instances it was exceedingly well marked, 
and in both it entirely disappeared when the symptoms abated. The 
probability of such a murmur being audible in cases of thrombosis 
of the pulmonary artery, has been recognized by one of our highest 
authorities in cardiac disease, who actually observed it in a non- 
puerperal case. In the last edition of his work on diseases of the 
heart, Dr. Walshe 2 says: "The only physical condition connected 
with the vessel itself would probably be systolic basic murmur fol- 
lowing the course of the pulmonary main trunk and of its immediate 
divisions to the left and right of the sternum. This sign I most 
certainly heard in an old gentleman whose life was brought to a 

1 Clinical Essays, p. 224 et sen. 

2 Walshe, On 'Diseases of the Heart, 4th ed. 1873. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 603 

sudden close, in the course of an acute affection, by coagulation in 
the pulmonary artery, and to a moderate extent in the right ven- 
tricle." 

Similar cases have, probably, been overlooked or misinterpreted. 
Many seem to have been attributed to shock, in the absence of a 
better explanation, a condition to which they bear no kind of re- 
semblance. 

Causes of Death. — The precise mode of death in pulmonary ob- 
struction, whether dependent on thrombosis or embolism, has given 
rise to considerable difference of opinion. Yirchow attributes it to 
syncope, 1 depending on stoppage of the cardiac contraction. Panum, 2 
on the other hand, contests this view, maintaining that the heart con- 
tinues to beat even after all signs of life have ceased. Certainly 
tumultuous and irregular pulsations of the heart are prominent 
) symptoms in most of the recorded cases, and are not reconcilable 
! with the idea of syncope. Panum's own theory is, that death is the 
| result of cerebral anaemia. Paget seems to think that the mode of 
death is altogether peculiar, in some respects resembling syncope, in 
others anaemia. Bertin, who has discussed the subject at great 
length, attributes the fatal result purely to asphyxia. The condition, 
! indeed, is in all respects similar to that state; the oxygenation of the 
blood being prevented, not because air cannot get to the blood, but 
because blood cannot get to the air. The symptoms also seem best 
explained by this theory ; the intense dyspnoea, the terrible struggle 
1 for air, the preservation of intelligence, the tumultuous action of the 
heart, are certainly not characteristic either of syncope or anaemia. 

Post-mortem Appearances of Clots. — The anatomical character of 
the clots seems to vary considerably. Ball, by whom they have been 
most carefully described, believes that they generally commence in 
the smaller ramifications of the arteries, extending backwards 
towards the heart, and filling the vessels more or less completely. 
Towards its cardiac extremity the coagulum terminates in a rounded 
head, in which respect it resembles those spontaneously formed in 
the peripheral veins. It is non-adherent to the coats of the vessels, 
and the blood circulates, when it can do so at all, between it and the 
vascular walls. Such clots are white, dense, and of a homogeneous 
structure, consisting of layers of decolorized fibrine, firm at the peri- 
phery, where the fibrine has been most recently deposited, and soft- 
ened in the centre, where amylaceous or fatty degeneration has 
commenced. Ball maintains that if the coagulum have commenced 
in the larger branches of the arteries, it must have first begun in 
the ventricle, and extended into them. According to Humphrey, 
the same changes take place in pulmonary as in peripheral thrombi, 
and they may become adherent to the walls of the vessels, or con- 
verted into threads or bands. When the obstruction is due to em- 
bolism, provided. the case is a well-marked one, and the embolus of 
some size, the appearances presented are different. We have no 
longer a laminated and decolorized coagulum, with a rounded head, 

1 Gesamm. Abhandl , 1862, p. 316. 2 Virchow's Arcliiv, 1863. 



604 THE PUERPERAL STATE. 

similar to a peripheral thrombus. The obstruction in this case 
generally takes place at the point of bifurcation of the artery, and 
we there meet with a grayish -white mass, contrasting remarkably 
with the more recently deposited fibrine before and behind it. It may 
be that the form of the embolus shows that it has recently been 
separated from a clot elsewhere; and in many cases it has been pos- 
sible to fit the travelled portion to the extremity of the clot from 
which it has been broken. We may also, perhaps, find that the 
embolus has undergone an amount of retrograde metamorphosis 
corresponding with that of the peripheral thrombus from which we 
suppose it to have come, but differing from that of the more recently 
deposited fibrine around it. It must be admitted, however, that the 
anatomical peculiarities of the coagula will by no means always 
enable us to trace them to their true origin. In many cases emboli 
may escape detection from their smallness, or from the quantity of 
fibrine surrounding them. 

Treatment. — But few words need be said as to the treatment of 
pulmonary obstruction. In a large majority of cases the fatal result 
so rapidly follows the appearance of the symptoms, that no time is 
given us even to make an attempt to alleviate the patient's suffer- 
ings. Should we meet with a case not immediately fatal, it seems 
that there are but two indications of treatment affording the slightest 
rational ground of hope : — 

1. To keep the patient alive by the administration of stimulants — 
brandy, ether, ammonia, and the like — to be repeated at intervals 
corresponding to the intensity of the paroxysms, and the results pro- 
duced. In the cases I have above narrated, in which recovery ensued, 
this took the place of all other medication. Possibly leeches, or dry 
cupping to the chest, might prove of some service in relieving the 
circulation. 

2. To enjoin the most absolute and complete repose. The object 
of this is evident. The only chance for the patient seems to be, that 
the vital functions should be carried on until the coagulum has been 
absorbed, or, at least, until it has been so much lessened in size as to 
admit of blood passing it to the lungs. The slightest movements 
may give rise to a fatal paroxysm of dyspnoea, from the increased 
supply of oxj^genated blood required. It must not be forgotten that 
in a large proportion of cases death immediately followed some exer- 
tion in itself trivial, such as rising out of bed. Too much attention, 
then, cannot be given to this point. The patient should be absolutely 
still; she should be fed with abundance of fluid food, such as milk, 
strong soups, and the like ; and should on no account be permitted 
to raise herself in bed, or attempt the slightest muscular exertion. 
If we are fortunate enough to meet with a case apparently tending 
to recovery, these precautions must be carried on long after the 
severity of the symptoms has lessened, for a moment's imprudence 
may suffice to bring them back in all their original intensity. 

Bertin, 1 indeed, recommends a system of treatment very different 

1 Op. cit. p. 393. 



PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 605 

i from this. In the vain hope that the violent effort induced may 
: cause the displacement of the impacted embolus (to which alone he 
attributes pulmonary obstruction), he recommends the administra- 
tion of emetics. Few, I fancy, will be found bold enough to attempt 
so hazardous a plan of treatment. 

Various drugs have been suggested in these cases. Richardson 
recommended ammonia, a deficiency of which he at that time believed 
to be the chief cause of coagulation. He has since advised that 
liquor ammonias should be given in large doses, 20 minims every 
hour, in the hope of causing solution of the deposited fibrine ; and 
he has stated that he has seen good results from the practice. Others 
advise the administration of alkalies, in the hope that they may 
favor absorption. The best that can be said for them is, that they 
are not likely to do much harm. 



CHAPTER VII. 

PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 

The same condition of the blood which so strongly predisposes to 
coagulation in the vessels through which venous blood circulates, 
tends to similar results in the arterial system. These, however, are 
by no means so common, and do not, as a rule, lead to such important 
consequences. The subject has been but little studied, and almost 
all our knowledge of it is derived from a very interesting essay by 
Sir James Simpson. 1 As I have devoted so much space to the con- 
sideration of venous thrombosis and embolism, I shall but briefly 
consider the effects of arterial obstruction. 

Causes. — In a considerable number of recorded cases the obstruc- 
tion has resulted from the detachment of vegetations deposited on 
|the cardiac valves, the result of endocarditis, either produced by 
(antecedent rheumatism, or as a complication of the puerperal state. 
(Sometimes the obstruction seems to depend on some general blood 
'dyscrasia, similar to that producing venous thrombosis, or on some 
j local change in the artery itself. Thus Simpson records a case ap- 
parently produced by local arteritis, which caused acute gangrene of 
both lower extremities, ending fatally in the third week after de- 
livery. In other cases it has been attributed to coagulation follow- 
I ing spontaneous laceration and corrugation of the internal coat of the 
artery. 

Symptoms. — The symptoms of puerperal arterial obstruction must, 
of course, vary with the particular arteries affected. Those, with 

1 Selected Obst. Works, vol. i. p. 523. 



606 THE PUERPERAL STATE. 

the obstruction of which we are most familiar, are the cerebral, the 
humeral, and the femoral. The effects produced must also be modi- 
fied by the size of the embolus, and the more or less complete ob- 
struction it produces. Thus, for example, if the middle cerebral 
artery be blocked up entirely, the functions of those portions of the 
brain supplied by it will be more or less completely arrested, and 
hemiplegia of the opposite side of the body, followed by softening of 
the brain-texture, will probably result. If the nervous symptoms 
be developed gradually, or increase in intensity after their first ap- 
pearance, it may be that an obstruction, at first incomplete, has in- 
creased by the deposition of fibrine around it. So the occasional 
sudden supervention of blindness, with destruction of the eyeball — 
cases of which are recorded by Simpson — not improbably depend on 
occlusion of the ophthalmic artery, the function of the organ de- 
pending on its supply through the single artery. The effects of ob- 
struction of the visceral arteries in the puerperal state are entirely 
unknown ; but it is far from unlikely that further investigation may 
prove them to be of great importance. In the extremities arterial 
obstruction produces effects which are well marked. They are classi- 
fied by Simpson under the following heads: 1. Arrest of pulse beloiu 
the site of obstruction. — This has been observed to come on either 
suddenly or gradually, and if the occlusion be in one of the large 
arterial trunks, it is a symptom which a careful examination will 
readily enable us to detect. 2. Increased force of pulsation in the ar- 
teries above the seat of obstruction. 3. Fall in the temperature of the 
limb. — This is a symptom which is easily appreciable by the ther- 
mometer, and, when the main artery of the limb is occluded, the 
coldness of the extremity is well marked. 4. Lesions of motor and 
sensory functions, paralysis, neuralgia, etc. etc. — Loss of power in the 
affected limb is often a prominent symptom, and when it comes on 
suddenly, and is complete, the main artery will probably be occluded. 
It may be diagnosed from paralysis depending on cerebral or spinal 
causes by the absence of head symptoms, by the history of the attack, 
and by the presence of other indications of arterial obstruction, such 
as loss of pulsation in the artery, fall of temperature, etc. The sen- 
sory functions in these cases are generally also seriously disturbed, 
not so much by loss of sensation, as by severe pain and neuralgia. 
Sometimes the pain has been excessive, and occasionally it has been 
the first symptom which directed attention to the state of the limb. 
5. Gangrene below or beyond the seat of arterial obstruction. — Several 
interesting cases are recorded, in which gangrene has followed arte- 
rial obstruction. Generally speaking gangrene will not follow 
occlusion of the main arterial trunk of an extremity, as the collateral 
circulation becomes soon sufficiently developed to maintain its vitality. 
In many of the cases either thrombi have obstructed the channels of 
collateral circulation as well, or the veins of the limb have also 
been blocked up. When such extensive obstructions occur they 
obviously cannot be embolic, but must depend on a local thrombosis, 
traceable to some general blood d} r scrasia depending on the puerperal 
state. 



CAUSES OF SUDDEX DEATH DURING LABOR. 607 

Treatment. — Little can be said as to the treatment of such cases, 
■which, must vary with the gravity and nature of the symptoms in 
each. Beyond absolute rest (in the hope of eventual absorption of 
the thrombus or embolus), generous diet, attention to the general 
health of the patient, and sedative applications to relieve the local 
pain, there is little in our power. Should gangrene of an extremity 
supervene in a puerperal patient, the case must necessarily be well- 
nigh hopeless. Simpson, however, records one instance in which 
amputation was performed above the line of demarcation, the patient 
eventually recovering. 



CHAPTEE VIII. 



OTHER CAUSES OF SUDDEN TDEATH DURING LABOR AND THE 
PUERPERAL STATE. 

A large number of the cases in which sudden death occurs during 
or after delivery find their explanation, as I have already pointed 
oat, in thrombosis or embolism of the heart and pulmonary arteries. 
Probably, many cases of the so-called idiopathic asphyxia were in 
fact examples of this accident, the true nature of which had been 
misunderstood. Besides these there are, no doubt, many other con- 
ditions which may lead to a suddenly fatal result in connection with 
parturition. 

Some of these are of an organic, others of a functional nature. 

Organic Causes. — Among the former may be mentioned cases in 
which the straining efforts of the second stage of labor have pro- 
duced death in patients suffering from some pre-existent disease of 
the heart. Euptare of that organ has probably occurred from fatty 
degeneration of its walls. Dehous 1 narrates an instance in which the 
efforts of labor caused the rapture of an aneurism. Another case, 
from interference with the action of the heart in a patient who had 
pericardial effusion, is narrated by Eamsbotham. Dr. Devilliers re- 
lates an instance occurring in a young woman during the second 
stage of labor. The heart was found to be healthy, bat the lungs 
were intensely congested, and blood was extensively extravasated 
all through their texture. This was probably caused by pulmonary 
congestion and apoplexy, produced by the severe straining efforts. 
Many cases from effusion of blood into the brain-substance, or on its 
surface, are on record, no doubt in patients who, from arterial de- 
generation or other causes, were predisposed to apoplectic effusions. 
The so-called apoj:>lectic convulsions, formerly described in most 

1 Dehous, Sur les Alorts subites. 



6C8 THE PUERPERAL STATE. 

works on obstetrics as a variety of puerperal convulsions, are evi- 
dently nothing more than apoplexy coming on during or after labor. 
As regards their pathology they do not seem to differ from ordinary 
cases of apoplexy in the non-pregnant condition. One example is 
recorded of death which was attributed to rupture of the diaphragm 
from excessive action in the second stage. 

Functional Causes. — Among the causes of death which cannot be 
traced to some distinct organic lesion, may be classed cases of syncope, 
shock, and exhaustion. Many instances of this kind are recorded. 
Thus in some women of susceptible nervous organization, the severity 
of the suffering appears to bring on a condition, similar to that pro- 
duced by excessive shock or exhaustion, which has not unfrequently 
proved fatal. Several examples of this kind have been cited by 
McClintock. 1 It is also not unlikely that sudden syncope sometimes 
produces a fatal result, during or after labor. Most cases of death, 
otherwise inexplicable, used to be referred to this cause ; but accu- 
rate autopsies were seldom made, and even when they were — -the 
important effects of pulmonary coagula being unknown — it is more 
than probable that the true cause of death was overlooked. It has 
been supposed that the sudden removal of pressure from the veins 
of the abdomen, by the emptying of the gravid uterus after delivery, 
may favor an increased afflux of blood into the lower parts of the 
body, and thus tend to an anaemic condition of the brain, and the 
production of syncope. However this may be, the possibility of its 
occurrence, and its manifest danger in a recently delivered woman, 
are sufficient reasons for enforcing the recumbent position after labor 
is over. In some of the cases the syncope was evidently produced 
by the patient's suddenly sitting upright. 

Death from Air in the Veins. — Some cases of sudden death imme- 
diately after labor seem to be due to the entrance of air into the 
veins. Six examples are cited by McClintock which were probably 
due to this cause. La Chapelle relates two. An interesting case is 
related by M. Lionet. 2 In this the patient died five and a half hours 
after an easy and natural labor, the chief symptoms being extreme 
pallor, efforts at vomiting, and dyspnoea. Air was found in the heart 
and in the arachnoid veins. There can be no question that the ute- 
rine sinuses after delivery are nearly as well adapted as the veins of 
the neck for allowing the entrance of air. They are firmly attached 
to the muscular walls of the uterus, so that they gape open when 
that organ is relaxed, and it is easy to understand how air might 
enter. Indeed, in the post-mortem examination in one of the cases 
occurring in the practice of Mme. La Chapelle, it is stated that "the 
uterine sinuses opened in the interior of the uterus by large orifices 
(one line and a half in diameter), through which air could readily be 
blown as far as the iliac veins, and vice versa. 11 The condition of 
the uterus after delivery also enables the air to have ready access to 
the mouths of the sinuses, for the alternate relaxation and contrac- 
tion of the uterus, occurring after the placenta is expelled, would 

1 Union Medic, 1853. 2 Delious, op. cit. p. 58. 



PERIPHERAL VENOUS THROMBOSIS, ETC. 609 

tend to draw in the air as by a suction pump. Hence, an additional 
reason for insisting on firm contraction of the uterus, as this will 
lessen the risk of this accident. 

Cause of Death in such Cases. — The precise mechanism of death 
from air in the veins has been a subject of dispute among patholo- 
gists. By Bichat, ' it was referred to anaemia and syncope from want 
of blood in the vessels of the brain, which are occupied by air ; 
Nysten 2 attributed it to distension of the cavities of the heart by 
rarefied air, producing paralysis of its walls ; Greroy to a stoppage of 
the pulmonary circulation, and consequent want of proper blood- 
supply to the left heart ; while Leroy d'Etoilles thought it might 
depend on any of these causes, or a combination of all of them. 
These, and many other hypotheses on the subject, have been ad- 
vanced, to all of which serious objection could be raised. The most 
recent theory is one maintained by Yirchow and Oppolzer, 3 and more 
recently by Feltz, which attributes the fatal results to impaction of 
the air-globules in the lesser divisions of the pulmonary arteries, 
where they form gaseous emboli, and cause death exactly in the same 
way as when the obstruction depends on a fibrinous embolus. The 
symptoms observed in fatal cases closely correspond to those of pul- 
monary obstruction, and it is not unlikely that some cases, attributed 
to other causes, may really depend on the entrance of air through 
the uterine sinuses. Such, for example, was most probably the 
explanation of a case referred to by Dr. Graily Hewitt in a discussion 
at the Obstetrical Society. 4 Death occurred shortly after the removal 
of an adherent placenta, during which, no doubt, air could readily 
enter the uterine cavity. The symptoms, viz., "severe pain in the 
cardiac region, distress as regards respiration, and pulselessness," are 
identical with those of pulmonary obstruction. Dr. Hewitt refers 
the death to shock, which certainly does not generally produce such 
phenomena. 



CHAPTER IX. 



PERIPHERAL VENOUS THROMBOSIS — (SYN. : CRURAL PHLEBITIS — 
PHLEGMASIA DOLEXS — ANASARCA SEROSA — OEDEMA LACTEUM — ■ 
WHITE LEG, ETC.). 

We now come to discuss the symptoms and pathology of the con- 
ditions associated with the formation of thrombi in the peripheral 
venous system, or rather in the veins of the lower extremities, since 

1 Recherches sur la Vie et la Mort, 1853. 

2 Nysten, Recherches de Phys. et Chem. Path., 1811. 

3 Casuistics des Embolie ; Wiener Med. "Woch , 1863. Des Embolics Capillaires, 
1868. Op. cit., p. 115. 

4 Obstet. Trans., vol. x. p. 28. 



610 THE PUERPERAL STATE. 

too little is known of their occurrence in other parts to enable us to 
say anything on the subject. 

The most important of these is the well-known disease which, 
under the name of phlegmasia dolens, has attracted much attention, 
and given rise to numerous theories as to its nature and pathology. 
In describing it as a local manifestation of a general blood-dyscrasia, 
and not as an essential local disease, I am making an assumption as 
to its pathology, that many eminent authorities would not consider 
justifiable. I have, however, already stated some of the reasons for 
so doing, and I shall shortly hope to show that this view is not 
incompatible with the most probable explanation of the peculiar 
state of the affected limb. 

Symptoms. — The first symptom which usually attracts attention is 
severe pain in some part of the limb that is about to be affected. 
The character of the pain varies in different -cases. In some it is 
extremely acute, and is most felt in the neighborhood of, and along 
the course of the chief venous trunks. It may begin in the groin or 
hip, and extend downwards ; or it may commence in the calf, and 
proceed upwards towards the pelvis. The pain abates somewhat 
after swelling of the limb (which generally begins within twenty - 
four hours), but it is always a distressing symptom, and continues as 
long as the acute stage of the disease lasts. The restlessness, want 
of sleep, and suffering which it produces are sometimes excessive. 
Coincident with the pain, and sometimes preceding it, more or less 
malaise is experienced. The patient may for a day or two be rest- 
less, irritable, and out of sorts, without any very definite cause; 
or the disease may be ushered in by a distinct rigor. Generally there 
is constitutional disturbance, varying with the intensity of the case. 
The pulse is rapid and weak, 120 or thereabouts; the temperature 
elevated from 101° to 102°, with an evening exacerbation. The pa- 
tient is thirsty; the tongue glazed, or white and loaded; the bowels 
constipated. In some few cases, when the local affection is slight, 
none of these constitutional symptoms are observed. 

Condition of the Affected Limb. — The characteristic swelling rapidly 
follows the commencement of the symptoms. It generally begins in 
the groin, from whence it extends downwards. It may be limited to 
the thigh ; or the whole limb, even to the feet, may be implicated. 
More rarely it commences in the calf of the leg, extending upwards 
to the thigh, and downwards to the feet. The affected parts have a 
peculiar appearance, which is pathognomonic of the disease. They 
are hard, tense, and brawny ; of a shiny, white color ; and not yield- 
ing on pressure, except towards the beginning and end of the illness. 
The appearances presented are quite different from those of ordinary 
oedema. When the whole thigh is affected the limb is enormously 
increased in size. Frequently the venous trunks, especially the 
femoral and popliteal veins, are felt obstructed with coagula, and 
rolling under the finger. They are painful when handled, and in 
their course more or less redness is occasionally observed. Either 
leg may be attacked, but the left more frequently than the right. 
There is a marked tendency for the disease to spread, and we often 



611 

find, in a case which is progressing apparently well, a rise of tem- 
perature and an accession of febrile symptoms, followed by the swell- 
ing of the other limb. 

Progress of the Disease. — After the acute stage has lasted from a 
week to a fortnight, the constitutional disturbance becomes less 
marked, the pulse and temperature fall, the pain abates, and the 
sleeplessness and restlessness are less, The swelling and tension of 
the limb now begin to diminish, and absorption commences. This is 
invariably a slow process. It is always many weeks before the effu- 
sion has disappeared, and it may be many months. The limb re- 
tains for a length of time the peculiar wooden feeling, as Dr. Churchill 
terms it. Any imprudence, such as a too early attempt at walking, 
may bring on a relapse and fresh swelling of the limb. This gradual 
recovery is by far the most common termination of the disease. In 
some rare cases suppuration may take place, either in the subcuta- 
neous cellular tissue, the lymphatic glands, or even in the joints, and 
death may result from exhaustion. The possibility of pulmonary 
obstruction and sudden death from separation of an embolus have 
already been pointed out, and the fact that this lamentable occurrence 
has generally followed some undue exertion should be borne in mind, 
as a guide in the management of our patient. 

Period of Commencement. — The disease usually begins within a 
short time after delivery, rarely after the second week. In 22 cases 
tabulated by Dr. Robert Lee, 7 were attacked between the fourth and 
twelfth days, and 14 after the second week, Some cases have been 
described as commencing even months after delivery. It is question- 
able if these can be classed as puerperal, for it must not be forgotten 
that phlegmasia dolens is by no means necessarily a puerperal disease. 
There are many other conditions which may give rise to it, all of 
them, however, such as produce a septic and hyperinosed state of the 
blood, such as malignant disease, dysentery, phthisis, and the like. 
My own experience would lead me to think that cases of this kind 
are much more common than is generally believed. 

History and Pathology. — The disease has long attracted the atten- 
tion of the profession. Passing over more or less obscure notices by 
Hippocrates, De Castro, and others, we find the first clear account in 
the writings of Mauriceau, who not only gave a very accurate de- 
scription of its symptoms, but made a guess at its pathology, which 
was certainly more happy than the speculations of his successors ; it 
is, he says, caused, " by a reflux on the parts of certain humors 
which ought to have been evacuated by the lochia." Puzos ascribed 
it to the arrest of the secretion of milk, and its extravasation in the 
affected limb. This theory, adopted by Levret and many subsequent 
writers, took a strong hold on both professional and public opinion, 
and to it we owe many of the names by which the disease is known 
to this day, such as oedema lacteum, milk leg, etc. In 1784 Mr. 
White, of Manchester, attributed it to some morbid condition of 
the lymphatic glands and vessels of the affected parts ; and this, or 
some analogous theory, such as that of rupture of the lymphatics 
crossing the pelvic brim, as maintained by Tyre, of Gloucester, or 



612 THE PUERPERAL STATE. 

general inflammation of the absorbents as held by Dr. Ferriar, was 
generally adopted. 

Phlebitic Theory. — It was not until the year 1823 that attention was 
drawn to the condition of the veins. To Bouillaud belongs the un- 
doubted merit of first pointing out that the veins of the affected limb 
were blocked up by coagula, although the fact had been previously 
observed by Dr. Davis, of University College. Dr. Davis made dissec- 
tions of the veins in a fatal case, and found, as Bouillaud had done, 
that they were filled with coagula, which he assumed to be the 
results of inflammation of their coats ; hence the name of " crural 
phlebitis" which has been extensively adopted instead of phlegmasia 
dolens. Dr. Kobert Lee did much to favor this view, and finding 
that thrombi were present in the iliac and uterine, as well as in the 
femoral, veins, he concluded that the phlebitis commenced in the 
uterine branches of the hypogastric veins, and extended downwards 
to the femorals. He pointed out that phlegmasia dolens was not 
limited to the puerperal state ; but that when it did occur independ- 
ently of it, other causes of uterine phlebitis were present, such as 
cancer of the os and cervix uteri. The inflammatory theory was 
pretty generally received, and even now is considered by many to be 
a sufficient explanation of the disease. Indeed the fact that more or 
less thrombus was always present could not be denied, and on the 
supposition that thrombus could only be caused by phlebitis, as was 
long supposed to be the case, the inflammatory theory was the natural 
one. Before long, however, pathologists pointed out that thrombosis 
was by no means necessarily, or even generally, the result of inflam- 
mation of the vessels in which the clot was contained, but that the 
inflammation was more generally the result of the coagulum. 

Theory of its Dependence on Septic Causes. — The late Dr. Mackenzie 
took a prominent part in opposing the phlebitic theory; He proved, 
by numerous experiments in the lower animals, that inflammation 
is not sufficient of itself to produce the extensive thrombi which are 
found to exist, and that inflammation originating in one part of a 
vein is not apt to spread along its canal, as the phlebitic theory 
assumes. His conclusion is, that the origin of the disease is rather 
to be sought in some septic or altered condition of the blood, pro- 
ducing coagulation in the veins. Dr. Tyler Smith 1 pointed out an 
occasional analogy between the causes of phlegmasia dolens and puer- 
peral fever, evidently recognizing the dependence of the former on 
blood dyscrasia. " I believe," he says, " that contagion and infection 
play a very important part in the production of the disease. I look 
on a woman attacked with phlegmasia dolens as having made a 
fortunate escape from the greater dangers of diffuse phlebitis or 
puerperal fever." In illustration of this he narrates the following 
instructive history : "A short time ago a friend of mine had been in 
close attendance on a patient dying of erysipelatous sore-throat with 
sloughing, and was himself affected with sore-throat. Under these 
circumstances, he attended, within the space of twenty-four hours, 

1 Tyler Smith, Manual of Obstetrics, p. 538. 



PUERPERAL VENOUS THROMBOSIS, ETC. 613 

three ladies in their confinements, all of whom were attacked with 
phlegmasia dolens." 

View of Tilbury Fox. — The latest important contribution to the 
pathology of the disease is contained in two papers by Dr. Tilbury 
Fox, published in the second volume of the " Obstetrical Transac- 
tions." He maintains that something beyond the mere presence of 
coagula in the veins is required to produce the phenomena of the 
disease, although he admits that to be an important, and even an 
essential, part of pathological changes present. The thrombi he be- 
lieves to be produced either by extrinsic or intrinsic causes : the 
former comprising all cases of pressure by tumor or the like ; the 
latter, and the most important, being divisible into the heads of — 

1. True inflammatory changes in the vessels, as seen in the epi- 
demic form of the disease. 

2. Simple thrombus, produced by rapid absorption of morbid 
fluid. 

3. Virus action and thrombus conjoined, the plegmasia dolens 
itself being the result of simple thrombus, and not produced by dis- 
eased (inflamed) coats of vessels ; the general symptoms the result of 
the general blood-state ; the virus present. 

He further points out that the peculiar swelling of the limbs can- 
not be explained by the mere presence of oedema, from which it is 
essentially different. The white appearance of the skin, the severe 
neuralgic pain, and the persistent numbness indicating that the whole 
of the cutaneous textures, the cutis vera and even the epithelial 
layer, are infiltrated with fibrinous deposit. He concludes, there- 
fore, that the swelling is the result of oedema plus something else ; 
that something being obstruction of the lymphatics, by which the 
absorption of effused serum is prevented. The efficient cause which 
produces these changes he believes to be, in the majority of cases, a 
septic action originating in the uterus, producing a condition similar 
to that in which phlegmasia dolens arises in the non -puerperal state. 

There is no doubt much force in Dr. Fox's arguments, and it may, 
I think, be conceded that obstruction of the veins per se is not suffi- 
cient to produce the peculiar appearance of the limb. It is, more- 
over, certain that phlebitis alone is also an insufficient explanation 
not only of the symptoms, but even of the presence of thrombi so 
extensive as those that are found. The view which traces the 
disease solely to inflammation or obstruction of lymphatics is purely 
theoretical, has no basis of facts to support it, and finds, nowadays, 
no supporters. The experiments of Mackenzie and Lee, as well as 
the vastly increased knowledge of the causes of thrombosis which 
the researches of modern pathologists have given us, seem to point 
strongly to the view already stated, that the disease can only be 
explained by a general blood dyscrasia, depending on the puerperal 
state. It by no means follows that we are to consider Dr. Fox's 
speculations as incorrect. It is far from improbable that the lym- 
phatic vessels are implicated in the production of the peculiar swell- 
ing, only we are not as yet in a position to prove it. There is no 
inherent improbability in the supposition that the same morbid 



614 THE PUERPERAL STATE. 

state of the blood which produces thrombosis in the veins, may also 
give rise to such an amount of irritation in the lymphatics as may 
interfere with their functions, and even obstruct them altogether. 
The essential and all-important point in the pathology of the disease, 
however, seems undoubtedly to be thrombosis in the veins; and the 
probability of there being some as yet undetermined pathological 
changes in addition to this, by no means militates against the view 
I have taken of the intimate connection of the disease with other 
results of thrombosis in more distant vessels. 

Changes Occurring in the Thrombi. — The changes which take place 
in the thrombi all tend to their ultimate absorption. These have 
been described by various authors as leading to organization or 
suppuration. It is probable, however, that the appearances which 
have led to such a supposition are fallacious, and that they are really 
due to retrograde metamorphosis of the flbrine, generally of an amy- 
laceous or fatty character. 

Detachment of Emboli. — The peculiarities of a clot that most favor 
detachment of an embolus are such a shape as admits of a portion 
floating freely in the blood current, by the force of which it is 
detached and carried to its ultimate destination. When the accident 
has occurred, it is often possible to recognize the peripheral thrombus 
from which the embolus has separated, by the fact of its terminal 
extremity presenting a freshly fractured end, instead of the rounded 
head natural to it. Such detachment is unlikely to occur, even 
when favored by the shape of the clot, unless sufficient time have 
elapsed after its formation to admit of its softening and becoming 
brittle. The curious fact I have before mentioned, of true puerperal 
embolism occurring, in the large majority of cases, only after the 
nineteenth day from delivery, finds a ready explanation in this 
theory, which it remarkably corroborates. 

Treatment. — On the supposition that phlegmasia dolens was the 
result of inflammation of the veins of the affected limb, an antiphlo- 
gistic course of treatment was naturally adopted. Accordingly, 
most writers on the subject recommend depletion, generally by the 
application of leeches, along the course of the affected vessels. We 
are told that if the pain continue the leeches should be applied a 
second, or even a third time. If we admit the septic origin of the 
disease we must, I think, see the impropriety of such a practice. 
The fact that it occurs, in a large majority of cases, in patients of a 
weakly and debilitated constitution, often in women who have 
already suffered from hemorrhage, is a further reason for not adopt- 
ing this routine custom. If local loss of blood be used at all, it should 
be strictly limited to cases in which there is much tenderness and 
redness along the course of the veins, and then only in patients of 
plethoric habit and strong constitution ; cases of this kind will form 
a very small minority of those coming under our observation. 

Over-active Treatment Unadvisable. — What has been said of the 
pathology of the affection tends to the conclusion that active treat- 
ment of any kind, in the hope of curing the disease, is likely to be 
useless. Our chief reliance must be on time and perfect rest, in 



PUERPERAL VENOUS THROMBOSIS, ETC. 615 



order to admit of the thrombi and the secondary effusion being 
absorbed; while we relieve the pain and other prominent symptoms, 
and support the strength and improve the constitution of the patient. 
Relief of Pain, etc. — The constant application of heat and moisture 
to the affected limb will do much to lessen the tension and pain. 
Wrapping the entire limb in linseed-meal poultices, frequently 
changed, is one of the best means of meeting this indication. If, as 
is sometimes the case, the weight of the poultices be too great to be 
readily borne, we may substitute warm flannel stupes, covered with 
oiled silk. Local anodyne applications afford much relief, and may 
be advantageously used along with the poultices and stupes, either 
by sprinkling their surface freely with laudanum, or chloroform and 
belladonna liniment, or by soaking the flannels in poppy-head fomen- 
tation. It is needless to say that the most absolute rest in bed should 
I be enjoined, even in slight cases, and that the limb should be effectu- 
1 ally guarded from undue pressure b}^ a cradle or some similar con- 
trivance. Local counter-irritation has been strongly recommended, 
and frequent blisters have been considered by some to be almost 
specific. I should myself hesitate to use blisters, as they would 
certainly not be soothing applications, and one hardly sees how they 
can be of much service in hastening the absorption of the effusion. 

Constitutional Treatment. — During the acute stage of the disease 
the constitutional treatment must be regulated by the condition of 
the patient. Light, but nutritious diet, must be administered in 
abundance, such as milk, beef-tea, and soups. Should there be much 
debility, stimulants in moderation may prove of service. With 
regard to medicines, we shall probably find benefit from such as are 
calculated to improve the condition of the blood and the general 
health of the patient. Chlorate of potash, with dilute hydrochloric 
acid, quinine, either alone or in combination with sesquicarbonate of 
ammonia, the tincture of the perchloride of iron, are the drugs that 
are most likely to prove of service. Alkalies and other medicines, 
which have been recommended in the hope of hastening the absorp- 
tion of coagula, must be considered as altogether useless. Pain must 
be relieved and sleep produced by the judicious use of anodynes, 
such as Dover's powder, the subcutaneous injection of morphia, or 
chloral. Generally no form answers so well as the hypodermic in- 
jection of morphia. 

Subsequent Local Treatment. — When the acute symptoms have 
abated, and the temperature has fallen, the poultices and stupes may 
be discontinued, and the limb swathed in a flannel roller from the 
toes upwards. The equable pressure and support thus afforded ma- 
terially aid the absorption of the effusion, and tend to diminish the 
size of the limb. At a still later stage very gentle inunctions of 
weak iodine ointment may be used with advantage once a day before 
the roller is applied. Shampooing and friction of the limb, generally 
recommended for the purpose of hastening absorption, should be 
carefully avoided, on account of the possible risk of detaching a 
portion of the coagulum, and producing embolism. This is no 
merely imaginary danger, as the following fact narrated by Trousseau 



616 THE PUERPERAL STATE. 

proves. "A phlegmasia alba dolens had appeared on the left side in 
a young woman suffering from peri-uterine phlegmon. The pain 
having ceased, a thickened venous trunk was felt on the upper and 
internal part of the thigh. Rather strong pressure was being made, 
when M. Demarquay felt something yield under his fingers. A few 
minutes afterwards the patient was attacked with dreadful palpita- 
tion, tumultuous cardiac action, and extreme pallor, and death was 
believed to be imminent. After some hours, however, the oppression 
ceased, and the patient eventually recovered. A slightly attached 
coagulum must have become separated, and conveyed to the heart 
or pulmonary artery." 1 Warm douches of water, of salt water if it 
can be obtained, may be advantageously used in the later stages of 
the disease, and they may be applied night and morning, the limb 
being bandaged in the interval. The occasional use of the electric 
current is said to promote absorption, and would seem likely to be a 
serviceable remedy. 

Change of Air, etc. — When the patient is well enough to be moved, 
a change of air to the seaside will be of value. Great caution, how- 
ever, should be recommended in using the limb, and it is far better 
not to run the risk of a relapse by any undue haste in this respect. 
It is well to warn the patient and her friends, that a considerable 
time must of necessity elapse, before the local signs of the disease 
have completely disappeared. 



CHAPTER X. 

PELVIC CELLULITIS AND PELVIC PERITONITIS. 

From the earliest time the occurrence after parturition of severe 
forms of inflammatory disease in and about the pelvis, frequently 
ending in suppuration, has been well known. It is only of late years, 
however, that these diseases have been made the subject of accurate 
clinical and pathological investigation, and that their true nature has 
begun to be understood. Nor is our knowledge of them as yet by 
any means complete. They merit careful study on the part of the 
accoucheur, for they give rise to some of the most severe and pro- 
tracted illnesses from which puerperal patients suffer. They are 
often obscure in their origin and apt to be overlooked, and they not 
rarely leave behind them lasting mischief. 

These diseases are not limited to the puerperal state. On the con- 
trary, many of the severest cases arise from causes altogether uncon- 
nected with child-bearing. These will not be now considered, and 

1 Trousseau, Clinique do l'Hotel-Dieu in Gaz. des Hop., 1860, p. 577. 



PELVIC CELLULITIS AXD PELVIC PERITONITIS. 617 

this chapter deals solely with such forms as may be directly traced 
to child-birth. 

Two Distinct Forms. — Eecent researches have demonstrated that 
there are two distinct varieties of inflammatory disease met with 
after labor, which differ materially from each other in many respects. 
In one of these, the inflammation effects chiefly the connective tissue 
surrounding the generative organs contained within the pelvis, or 
i extends up from it beneath the peritoneum, and into the iliac fossae. 
In the other, it attacks that portion of the peritoneum which covers 
the pelvic viscera, and is limited to it. 

So much is admitted by all writers, but great obscurity in descrip- 
tion, and consequent difficulty in understanding satisfactorily the 
nature of these affections, have resulted from the variety of nomen- 
clature which different authors have adopted. 

Thus the former disease has been variously described as pelvic 
cellulitis, peri-uterine phlegmon, para-metritis, or pelvic abscess, 
while the latter is not unfrequently called peri-metritis, as contra- 
distinguished from para-metritis. The use of the prefix para ov peri, 
to distinguish the cellular or peritoneal variety of inflammation, 
originally suggested by Virchow, has been pretty generally adopted 
in Germany, and has been strongly advocated in this country by 
Matthews Duncan. It has never, however, found much favor with 
English writers, and the similarity of the two names is so great as to 
lead to confusion. I have, therefore, selected the terms " pelvic peri- 
tonitis" and "pelvic cellulitis" as conveying in themselves a fairly 
accurate notion of the tissues mainly involved. 

Importance of Distinguishing the Two Classes of Cases. — The im- 
portant fact to remember is that there exist two distinct varieties of 
inflammatory disease, presenting many similarities in their course, 
symptoms, and results, often occurring simultaneously, but in the 
main distinct in their pathology, and capable of being differentiated. 
Thomas compares them — and, as serving to fix the facts on the 
memory, the illustration is a good one — to pleurisy and pneumonia. 
"Like them," he says, "they are separate and distinct, like them 
affect different kinds of structure, and like them they generally com- 
plicate each other." It might, therefore, be advisable, as most 
writers on the disease occurring in the non-puerperal state have 
done, to treat of them in two separate chapters. There is, however, 
more difficulty in distinguishing them as puerperal than as non-puer- 
peral affections, for which reason, as well as for the sake of brevity, 
I think it better to consider them together, pointing out, as I pro- 
ceed, the distinctive peculiarities of each. 

Seat of Disease. — When attention was first directed to this class of 
diseases, the pelvic cellular tissue was believed to be the only struc- 
ture affected. This was the vieAV maintained by Nonat, Simpson, 
and many modern writers. Attention was first prominently directed 
to the importance of localized inflammation of the peritoneum, and 
to the fact that many of the supposed cases of cellulitis were really 
peritonitic, by Bernutz. There can be no doubt that he here made 
an enormous step in advance. Like many authors, however, he rode 
40 



618 THE PUERPERAL STATE. 

his hobby a little too hard, and he erred in denying the occurrence 
of cellulitis in many cases in which it undoubtedly exists. 

Etiology. — The great influence of child-birth in producing these 
diseases has loug been fully recognized. Courty estimates that about 
two-thirds of all the cases met with occur in connection with de- 
livery or abortion, and Duncan found that out of 40 carefully observed 
cases, 25 were associated with the puerperal state. 

The Inflammation is Secondary and never Idiopathic. — It is pretty 
generally admitted by most modern writers that both varieties of the 
disease are produced by the extension of inflammation from either 
the uterus, the Fallopian tubes, or the ovaries. This point has been 
especially insisted on by Duncan, who maintains that the disease is 
never idiopathic, and is "invariably secondary either to mechanical 
injury, or to the extension of inflammation of some of the pelvic vis- 
cera, or to the irritation of the noxious discharges through or from 
the tubes or ovaries." 

Often intimately connected ivith Septicaemia. — Their intimate con- 
nection with puerperal septicaemia is also a prominent fact in the 
natural history of the diseases. Barker mentions a curious observa- 
tion illustrative of this, that when puerperal fever is endemic in the 
Bellevue Hospital in New York, cases of pelvic peritonitis and cel- 
lulitis are also invariably met with. Olshausen has also remarked 
that in the Lying-in Hospital at Halle, during the autumn vacation, 
when the patients are not attended by practitioners, and when, there- 
fore, the chance of septic infection being conveyed to them is less, 
these inflammations are almost always absent. As inflammation of 
the lining membrane of the uterus, of the vaginal mucous membrane, 
and of the pelvic connective tissue, are of very constant occurrence 
as local phenomena of septic absorption, the connection between the 
two classes of cases is readily susceptible of explanation. Schroeder, 
indeed, goes further, and includes his description of these dis- 
eases under the head of puerperal fever. They do not, however, 
necessarily depend upon it ; for, although it must be admitted that 
cases of this kind form a large proportion of those met with, others 
unquestionably occur which cannot be traced to such sources, but are 
the direct result of causes altogether unconnected with the inflam- 
mation attending on septic absorption, such as undue exertion shortly 
after delivery, or premature coition. Mechanical causes may be- 
yond doubt excite the disease in a woman predisposed by the puer- 
peral process, but they cannot fairly be included under the head of 
puerperal fever. 

Seat of the Inflammation in Pelvic Cellulitis. — Abundance of areolar 
tissue exists in connection with the pelvic viscera, which may be the 
seat of cellulitis. It forms a loose padding between the organs con- 
tained in the pelvis proper, surrounds the vagina, the rectum, and 
the bladder, and is found in considerable quantity between the folds 
of the broad ligaments. From these parts it extends upwards to the 
iliac fossae, and the inner surface of the abdominal parietes. In any 
of these positions it may be the seat of the kind of inflammation we 
are discussing. The essential character of the inflammation is similar 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 619 

to that which accompanies areolar inflammation in other parts of the 
body. There is first an acute inflammatory oedema, followed by the 
infiltration of the areolae of the connective tissue with exudation, 
and the consequent formation of appreciable swellings. These may 
form in any part of the pelvis. Thus we may meet with them, and 
this is a very common situation, between the folds of the broad 
ligaments, forming distinct hard tumors, connected with the uterus, 
and extending to the pelvic walls, their rounded outlines being readily 
made out by bi-rnanual examination. If the cellulitis be limited in 
extent, such a swelling may exist on one side of the uterus only, 
forming a rounded mass of varying size, and apparently attached to 
it. At other times the exudation is more extensive, and may com- 
pletely or partially surround the uterus, extending to the cellular 
tissue between the vagina and rectum, or between the uterus and 
the bladder. In such cases the uterus is imbedded and firmly fixed 
in dense, hard exudation. At other times, the inflammation chiefly 
affects the cellular tissue covering the muscles lining the iliac fossae. 
There it forms a mass, easily made out by palpation, but on vaginal 
examination little or no trace of the exudation can be felt, or only a 
sense of thickness at the roof of the vagina on the same side as the 
swelling. 

Seat of the Inflammation in Pelvic Peritonitis. — In pelvic peritonitis 
the inflammation is limited to that portion of the peritoneum which 
invests the pelvic viscera. Its extent necessarily varies with the 
intensity and duration of the attack. In some cases there may be 
little more than irritation, while more often it runs on to exudation 
of plastic material. The result is generally complete fixation of the 
uterus, and hardening and swelling in the roof of the vagina; and 
the lymph poured out may mat together the surrounding viscera, so 
as to form swellings, difficult, in some cases, to differentiate from 
those resulting from cellulitis. On post-mortem examination the 
pelvic viscera are found extensively adherent, and the agglutination 
may involve the coils of the intestine in the vicinity, so as sometimes 
to form tumors of considerable size. 

Relative Frequency of the Two Forms of Disease. — The relative fre- 
quency of these two forms of inflammation as puerperal affections is 
not easy to ascertain. In the non-puerperal state the peritonitic 
variety is much the more common, but in the puerperal state they 
very generally complicate each other, and it is rare for cellulitis to 
exist to any great extent without more or less peritonitis. 

Symptomatology . — The earliest symptom is pain in the lower part 
of the abdomen, which is generally preceded by rigor or chilliness. 
The amount of pain varies much. Sometimes it is comparatively 
slight, and it is by no means rare to meet with patients, who are the 
subjects of very considerable exudations, who suffer little more than 
a certain sense of weight and discomfort at the lower part of the 
abdomen. On the other hand the suffering may be excessive, and is 
characterized by paroxysmal exacerbations, the patient being com- 
paratively free from pain for several successive hours, and then 
having attacks of the most acute agony. Schroeder says that pain 



620 THE PUERPERAL STATE. 

is always a symptom of peritonitis, and that it does not exist in 
uncomplicated cellulitis. The swellings of cellulitis are certainly 
sometimes remarkably free from tenderness, and I have often seen 
masses of exudation in the iliac fossae, which could bear even rough 
handling. On the other hand, although this is certainly more often 
met with in non-puerperal cases, the tenderness over the abdomen is 
sometimes excessive, the patient shrinking from the slightest touch. 
The pulse is raised, generally from 100 to 120, and the thermometer 
shows the presence of pyrexia. During the entire course of the 
disease both these symptoms continue. The temperature is often 
very high, but more frequently it varies from 100° to 104°, and it 
generally shows more or less marked remissions. In some cases the 
temperature is said not to be elevated at all, or even to be sub-nor- 
mal, but this is certainly quite exceptional. Other signs of local 
and general irritation often exist. Among them, and most distinctly 
in cases of peritonitis, are nausea and vomiting, and an anxious 
pinched expression of the countenance, while the local mischief often 
causes distressing dysuria and tenesmus. The latter is especially 
apt to occur when there is exudation between the rectum and vagina, 
which presses on the bowel. The passage of feces, unless in a very 
liquid form, may then cause intolerable suffering. 

Such symptoms may show themselves within a few days after 
delivery, and then they can harely fail to attract attention. On the 
other hand, they may not commence for some weeks after labor, and 
then they are often insidious in their onset, and apt to be overlooked. 
It is far from rare to meet with cases six weeks or more after con- 
finement, in which the patient complains of little beyond a feeling 
of malaise and discomfort, and in which, on investigation, a conside- 
rable amount of exudation is detected, which had previously entirely 
escaped observation. 

Results of Physical Examination. — On introducing the finger into 
the vagina it will be found to be hot and swollen, in some cases dis- 
tinctly oedematous, and on reaching the vaginal cul-de-sac the exist- 
ence of exudation may generally be made out. The amount of this 
varies much. Sometimes, especially in the early stage of the disease, 
there is little more than a diffuse sense of thickness and induration 
at either side of, or behind, the uterus. More generally careful 
bi-manual examination enables us to detect a distinct hardening and 
swelling, . possibly a tumor of considerable size, which may appa- 
rently be attached to the sides of the uterus, and rise above the 
pelvic brim, or may extend quite to the pelvic walls. The examina- 
tion should be very carefully and systematically conducted with 
both hands, so as to explore the whole contour of the uterus before, 
behind, and on either side, as well as the iliac fossos ; otherwise a 
considerable exudation might readily escape detection. When the 
exudation is at all great, more or less fixity of the uterus is sure to 
exist, and is a very characteristic symptom. The womb, instead of 
being freely movable by the examining finger, is firmly fixed by the 
surrounding exudation, and in severe forms of the disease is quite 
encased in it. More or less displacement of the organ is also of 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 621 

common occurrence. If the swelling be limited to one side of the 
pelvis or to Douglas's space, the uterus is displaced in the opposite 
direction, so that it is no longer in its usual central position. 

The Two Forms of Disease cannot always be Distinguished. — The 
differential diagnosis of pelvic cellulitis and pelvic peritonitis cannot 
always be made, and, indeed, in many cases it is impossible, since 
both varieties of disease coexist. The elements of differentiation 
generally insisted on are, the greater general disturbance, nausea, 
etc., in pelvic peritonitis, with an earlier commencement of the symp- 
toms after labor. The swellings of pelvic peritonitis are also more 
tender, with less clearly-defined outline than those of cellulitis. 
When the cellulitis involves the iliac fossa the diagnosis is, of course, 
easy, and then a continuous retraction of the thigh on the affected 
side (an involuntary position assumed with the view of keeping the 
muscles lining the iliac fossa at rest), is often observed. When the 
inflammation is chiefly limited to the cavity of the pelvis, the dis- 
tinction between the two classes of cases cannot be made with any 
degree of certainty. 

Terminations. — Both forms of disease may end either in resolution 
or in suppuration. In the former case, after the acute symptoms 
have existed for a variable time, it may be for a few daj^s only, it 
m&y be for many weeks, their severity abates, the swellings become 
less tender and commence to contract, become harder and are gradu- 
ally absorbed ; until, at last, the fixity of the uterus disappears, and 
it again resumes its central position in the pelvic cavity. This pro- 
cess is often very gradual. If is by no means rare to find a patient, 
even some months after the attack, when all acute symptoms have 
long disappeared, who is even able to move about without incon- 
venience, in whom the uterus is still immovably fixed in a mass of 
deposit, or is, at least, adherent in some part of its contour. More 
or less permanent adhesions are of common occurrence, and give 
rise to symptoms of considerable obscurity, which are often not 
traced to their proper source. 

Symptoms of Suppuration. — When the inflammation is about to 
terminate in suppuration, the pyrexial symptoms continue, and 
eventually well-marked hectic is developed, the temperature gene- 
rally showing a distinct exacerbation at night, At the same time 
rigors, loss of appetite, a peculiar yellowish discoloration of the face, 
and other signs of suppuration, show themselves. The relative fre- 
quency of this termination is variously estimated by authors. Duncan 
quotes Simpson as calculating it as occurring in half the cases of 
pelvic cellulitis, but states his own belief that it is much more frequent. 
West observed it in 23 out of 43 cases following delivery or abor- 
tion, and McClintock in 37 out of 70. Schroeder says that he has 
only once seen suppuration in 92 cases of distinctly demonstrable 
exudation, a result which is certainly totally opposed to common 
experience. Barker also states that in his experience suppuration 
in either pelvic peritonitis or cellulitis " is very rare, except when 
they are associated with pyaemia or puerperal fever." It is certain 
that suppuration is more likely to occur in pelvic cellulitis than in 



622 THE PUERPERAL STATE. 

pelvic peritonitis, but it unquestionably occurs, in this country at 
least, much more frequently than the statements of either of these 
authors would lead us to suppose. 

Channels through which Pus may Escape. — The pus may find an 
exit through various channels. In pelvic cellulitis, more especially 
when the areolar tissue of the iliac fossa is implicated, the most 
common site of exit is through the abdominal wall. It may, how- 
ever, open at other positions, and the pus may find its way through 
the cellular tissue and point at the side of the anus, or in the vagina, 
or it may take even a more tortuous course and reach the inner sur- 
face of the thigh. Pelvic abscesses not uncommonly open into the 
rectum or bladder, causing very considerable distress from tenesmus 
or dysuria. According to Hervieux, it is chiefly the peritoneal 
varieties which open in this way. Not unfrequently more than one 
opening is formed; and when the pus has burrowed for any dis- 
tance, long fistulous tracts result, which secrete pus for a length of 
time, and are very slow to heal. Eupture of an abscess into the 
peritoneal cavity, especially of a peritonitic abscess, is a possible 
(but fortunately a very rare) termination, and will generally prove 
fatal by producing general peritonitis. In one case which I have 
recorded in the fifteenth volume of the ''Obstetrical Transactions," 
suppuration was followed by extensive necrosis of the pelvic bones. 
Two similar cases are related by Trousseau in his " Clinical Medi- 
cine," but I have not been able to meet with any other examples of 
this rare complication, which was probably rather the result of some 
obscure septicemic condition than of extension of the inflammation. 

Prognosis. — The prognosis is favorable as regards ultimate re- 
covery, but there is greak risk of a protracted illness which may 
seriously impair the health of the patient, especially if suppuration 
result. Hence it is necessary to be guarded in an expression of 
opinion as to the consequences of the disease. Secondary mischief 
is also far from unlikely to follow, from the physical changes pro- 
duced by the exudation, such as permanent adhesions or malpositions 
of the uterus, or organic alterations in the ovaries or Fallopian tubes. 

Treatment. — In the treatment of both forms of disease the import- 
ant points to bear in mind are the relief of pain, and the necessity 
of absolute rest ; and to these objects all our measures must be sub- 
ordinate, since it is quite hopeless to attempt to cut short the inflam- 
mation by any active medication. 

If the disease be recognized at a very early stage, the local abstrac- 
tion of blood, by the application of a few leeches to the groin or to the 
hemorrhoidal veins, may give relief; but the influence of this remedy 
has been greatly exaggerated, and when the disease is of any standing 
it is quite useless. Leeches to the uterus, often recommended, are, I 
believe, likely to do more harm than good (unless in very skilful 
hands), from the irritation produced by passing the speculum. Opi- 
ates in large closes may be said to be our sheet anchor in treatment 
whenever the pain is at all severe, either by the mouth, in the form 
of morphia suppositories, or injected subcutaneousfy. In the not 
uncommon cases in which pain comes on severely in paroxysms, the 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 623 

opiates should be administered in sufficient quantity to lull the pain, 
and it is a good plan to give the nurse a supply of morphia supposi- 
tories (which often act better than any other form of administering 
the drug), with directions to use them immediately the pain threatens 
to come on. When there is much pyrexia large doses of quinine 
may be given with great advantage, along with the opiates. The 
state of the bowels requires careful attention. The opiates are apt 
to produce constipation, and the passage of hardened feces causes 
much suffering. Hence it is desirable to keep the bowels freely 
open. Nothing answers this purpose so well as small doses of castor 
oil, such as half a teaspoonful given every morning. Warmth and 
moisture, constantly applied to the lower part of the abdomen, give 
great relief either in the form of large poultices of linseed meal, or, 
if these prove too heavy, of spongio-piline soaked in boiling water. 
The poultices may be advantageously sprinkled with laudanum or 
belladonna liniment. I say nothing of the use of mercurials, iodide 
of potassium, and other so-called absorbent remedies, since I believe 
them to be quite valueless, and apt to divert attention from more 
useful plans of treatment. 

Importance of Rest. — The most absolute rest in the recumbent posi- 
tion is essential, and it should be persevered in for some time after 
the intensity of the symptoms is lessened. The beneficial effect of 
rest in alleviating pain is often seen in neglected cases, the nature of 
which has been overlooked, instant relief following the laying up 
of the patient. 

Counter- Irritation. — When the acute symptoms have lessened, ab- 
sorption of the exudation may be favored, and considerable relief 
obtained, from counter-irritation, which should be gentle and long- 
continued. The daily use of tincture of iodine until the skin peels, 
perhaps best meets this indication ; but frequently repeated blisters 
are often very serviceable. This I believe to be a better plan than 
keeping up an open sore with savine ointment, or similar irritating 
applications. 

Opening of Pelvic Abscesses. — When suppuration is established the 
question of opening the abscess arises. When this points in the 
groin, and the matter is superficial, a free incision may be made, and 
here, as in mammary abscess, the antiseptic treatment is likely to 
prove very serviceable. The abscess should, however, not be opened 
too soon, and it is better to wait until the pus is near the surface. 
The importance of not being in too great a hurry to open pelvic 
abscesses has been insisted on by West, Duncan, and other writers, 
and I have no doubt the rule is a good one. It is more especially 
applicable when the abscess is pointing in the vagina or rectum, 
where exploratory incisions are apt to be dangerous, and when the 
presence of pus should be positively ascertained before operating. 
We have in the aspirator a most useful instrument in the treatment 
of such cases, which enables us to remove the greater part of the pus 
without any risk, and the use of which is not attended with danger, 
even if employed prematurely. If it do not sufficiently evacuate the 
abscess, a free opening can afterwards be safely made with the bis- 



bZi THE PUERPERAL STATE. 

toury. The surgical treatment of pelvic abscess is, however, too wide 
a subject to admit of being satisfactorily treated here. 

Diet and Regimen. — The diet should be abundant, but simple and 
nutritious. In the early stages of the disease, milk, beef-tea, eggs, 
and the like, will be sufficient. After suppuration a large quantity 
of animal food is required, and a sufficient amount of stimulants. 
The drain on the system is then often very great, and the amount of 
nourishment patients will require and assimilate, when a copious 
purulent discharge is going on, is often quite remarkable. A general 
tonic plan of medication will also be required, and such drugs as 
iron, quinine, and cod-liver oil, will prove useful. 



[APPENDIX. 



THE INTRA- VENOUS INJECTION OF FRESH MILK, AS AN IMPROVED 
SUBSTITUTE FOR THE TRANSFUSION OF BLOOD. 

The introduction of freshly drawn, blood- warm milk, of the cow 
and goat, into the veins of an exhausted patient, whether the condi- 
tion is the result of hemorrhage or disease, is not altogether new as 
a means of physical restoration, but has been recently revived with 
improvements, both as to method and application, by several Ame- 
rican physicians, most prominent among whom is Dr. T. Gaillard 
Thomas, of New York. 

The credit of the initiative revival is due to Dr. Edward M. 
Hodder, of Toronto, Canada, who made use of it in the collapse of 
Asiatic cholera, with the saving of two patients, in the epidemic of 
1850, when warm water, artificial serum, etc., were being injected 
experimentally but ineffectually into the bloodvessels of patients. 
Dr. Joseph W. Howe, of New York, instituted a series of experi- 
ments upon dogs ; but, using milk brought from the country, all of 
his animals promptly died. Dr. Depuy repeated the same, with 
immediately drawn milk, and found the fluid perfectly harmless in 
this form. Dr. Howe injected, also, f 3yj of goat's milk into the 
cephalic vein of a patient affected with phthisis, with success, so far 
as the immediate effect was concerned. 

Dr. Thomas presented an account of his cases in a paper read 
before the New York Academy of Medicine last spring, an abridg- 
ment of which appeared in the Medical Record of April 27th, 1878. 
His first trial was made in October, 1875, in a case of uterine hemor- 
rhage following ovariotomy, with f Jviiiss of warm and freshly drawn 
cow's milk, the medium of introduction being a glass funnel, India- 
rubber tube, and nozzle. A rigor resulted, followed by a rise of 
temperature to 101°, but these symptoms soon disappeared. The 
patient made a good recovery, being clown stairs on the twenty -first 
day. 

In a second ovarian case, Dr. Thomas injected on five occasions, 
from f |vj up to f 3xv, in a period of ten clays ; and although the 
patient died of intestinal gangrene, the impression was that the milk 
had prolonged her life about six days. 

As far as we have ascertained, there have been fifteen patients 
under treatment by this method, viz., Dr. Hodder, three cases ; Dr. 



626 APPENDIX. 

Howe, two ; Dr. Thomas, seven ; and Dr. Charles T. Hunter, of Phila- 
delphia, three. 

Dr. Hunter greatly prefers this method to that of the transfusion 
of blood, over which it has many advantages, both in introduction 
and result. He has the milk drawn into a double vessel, with warm 
water in the interspace, and regulates the temperature to about 99° 
Fahr. The fluid is strained through fine wire gauze, to exclude any 
foreign matters that might be injurious. Attached to the funnel and 
tube, Dr. Hunter has a perforating canula, with a small stopcock to 
shut off the flow of milk. After the vein is fully exposed, the milk 
is ran through the tube, the cock closed, which keeps the canula full 
by capillary attraction, and the vessel perforated by the cutter on the 
end of the canula ; the cock is then opened, funnel elevated, and 
milk carried in by its own weight. He has used cows' milk in two 
cases, and goats' milk in the third and last. He objects to the use of 
the syringe as much more troublesome and less safe than the simple 
fountain apparatus described. 

The milk used should not only be just drawn, but perfectly free 
from any acidity, as shown by test-paper. In hot weather, the passage 
of milk through the air from the udder to the vessel will develop a 
slight formation of lactic acid, which should be neutralized by the 
addition of bicarbonate of soda. Dr. A. Jacobi, in the discussion of 
Dr. Thomas's paper, stated that the milk of some cows was acid while 
still in the uclder. The cow, or goat, should be fed upon grass or 
fine hay, and be milked as near to the patient as possible, into the 
double vessel already described, or, what will answer, a clean farina- 
boiler or glue-pot, both of which are double-cased. In the country 
this can be readily managed so far as the cow is concerned, as she 
can be driven to the door to be milked ; but in cities there is much 
more difficulty, where this animal is rarely kept, and we are obliged 
to use the goat as a substitute, feeding her in the yard or cellar for 
the time wanted. No doubt the milk of the ass or mare, when at 
hand, would answer equally well. Both Dr. Thomas and Dr. Hunter 
believe that a measure of f Jviij is sufficient for ordinary use, although 
the former has used as high as fifteen, and the latter ten. We be- 
lieve that the size of the patient should make a difference in the 
number of ounces to be employed, just as it does in the volume of 
blood naturally in the body, the range in the extremes being con- 
siderable. As chyle varies in color and analysis according to the 
food consumed, being most nearly allied to milk when the animal 
has been fed with it, there must be in the blood a capability of con- 
version, of a variable character, which enables it to alter, not only 
the extremes of the chylous fluid, but milk also, with its butter and 
casein, which are not found in chyle. Pure milk has been satisfac- 
torily proved to be innocent in the blood when properly collected 
and introduced ; and not only this, but also a valuable means of 
saving life in cases of extreme prostration. How it acts, we do not 
understand ; or why it will answer as well as, or better than, blood ; 
we are satisfied that it does, and are prepared to recommend it to 
our readers. 



APPENDIX. 627 

"We have -a patient, almost in articulo- mortis, pale, prostrate, per- 
haps emaciated and anasmic, lying in a semi-comatose sleep, into 
whose veins we inject a half pint of pure, warm, new milk. She 
has a chill, then a considerable rise of temperature, and finally opens 
her eyes and appears for the time as one almost awakened from the 
sleep of death. If the condition of the patient is not necessarily fatal, 
by reason of its destructive progress, we may bridge over the period 
of danger until convalescence is established, and thus save the case. 
Milk has done this when food and stimulants appeared to be unavail- 
able ; and we have faith to believe, that it has a future of much use- 
fulness in a great variety of cases. To make known its value, is to 
largely increase its sphere of usefulness in general practice. — Ed.] 



INDEX 



ABDOMEN, adipose enlargement of, 148 
enlargement of, as a sign of preg- 
nancy, 139 

state of, after delivery, 526 
■Abdominal pregnancy. (See Extra-uterine 
| pregnancy.) 
Abortion, 229 

causes of, 231 

difficulty in procuring artificial, 230 

liability to recurrence of, 230 

retention of secundines in, 235, 240 

symptoms of, 235 

treatment of, 235 

production of, in vomiting of preg- 
nancy, 187 

[value of opium in prevention of, 236] 
Abscess of mammae. (See Mammary ab- 
scess.) 
'Abscess, pelvic. (See Pelvic cellulitus.) 
After-pains, 529 

treatment of, 531 
Age, influence of, in labor, 328 
Albuminuria in pregnancy, 192 

relation of, to eclampsia, 550 

relation of, to puerperal insanity, 563 
Allantois, 96 
Amnion, formation of, 95 

pathology of, 223 

structure of, 98 
Amputations (intra-uterine), 226 
Anaemia in pregnancy, 191 
Anaesthesia in labor, 282 

in forceps operations, 465 

value of, in difficult cases of turning, 
457 
Anasarca in pregnancy, 194 
Ante-version of the gravid uterus, 202 
Apoplexy during or after labor, 550, 606 
Arbor vitas, 51 
Area germinativa, 94 
Area pellucida, 95 
Areola, 70 

changes of, during pregnancy, 136 
Arm, presentation of. (See Shoulder pre- 
sentation.) 

dorsal displacement of, 318 
Artificial human milk, 547 
Artificial respiration in cases of apparent I 

still-birth, 534 
Ascites as a cause of dystocia; 364 
Asphyxia (idiopathic), 607 



[Atmosphere, advantages of a pure, in 

preventing abortion, 237] 
Auscultatory signs of pregnancy, 142 



BAGS (Barnes's). (See Dilators.) 
Ballottement, 141 
Bi-lobed uterus, gestation in, 180 
Binder, uses of, 281 

Bladder, distension of, as a cause of pro- 
tracted labor, 328 
state of, after delivery, 530 
Blastodermic membrane, 88 

division and layers of, 94 
Blood, alteration in, after delivery, 524 
Blood-diseases transmitted to foetus, 223 
Blunt-hook in breech presentation, 297 
Bowels, action of, after delivery, 532 
Breech presentations. (See Pelvic pre- 
sentations.) 
Broad ligaments of uterus, 59 
[Bromide of sodium preferred to bromide 

of potassium, 196] 
Bronchitis as a cause of protracted labor, 

328 
Brow presentations, 306 



p^SAREAN section, 203, 317, 345, 375, 






499 



causes of mortality after, 504 
causes requiring the operation, 

501 
description of, 508 
history of, 499 
post-mortem operation, 503 
results to child in, 501 
statistics of, 501 
substitutes for, 510 
[Caesarean operation in the United States, 
512] 
[carbolized catgut sutures in, 

509] 
[transverse position of foetus, 
499] 
Calculus of bladder obstructing labor, 347 
Caput succedaneum, 266 
Carcinoma in pregnancy, 209 

obstructing labor, 314 
Caries of teeth in pregnancy, 190 
Carunculae myrtiformes, 44 



630 



INDEX 



[Catheter introduced in dorsal decubitus, 
43] 
introduction of, 43 
Caul, 251 

Cellulitis, pelvic. (See Pelvic cellulitis.) 
Cephalotribe, 487 

Cephalotripsy. (See Craniotomy.) 
Cervix uteri, 51 

alterations of, after childbirth, 50 
cavity of, 50 

dilatation of, in labor, 246 
impaction of, before foetal head, 

274 
incision of, for rigidity, 342 
modification of, by pregnancy, 

126 
mucous membrane of, 55 
organic causes of rigidity of, 341 
rigidity of, as a cause of pro- 
tracted labor, 339 
treatment of rigidity, 340 
villi of, 55 
Charlotte, Princess of Wales, death of, 336 
Child (the new born). (See Infant.) 
Child, risks to, in forceps operations, 472 
Childbirth, mortality of, 523 
Chloral in labor, 283 

in rigidity of cervix, 340 
Chloroform in labor, 283 

in difficult cases of turning, 457 
in rigidity of cervix, 340 
Chorea in pregnancy, 198 
Chorion, 99 

vesicular degeneration of, 215 
Circulation of foetus, 119 
Cleavage of yelk, 88 
Clitoris, 42 
Coccyx, 27 

ligaments of, 28 
ossification of, 28 
mobility of, 28 
Cold in the treatment of puerperal hyper- 
pyrexia, 592 
Colostrum, 536 
Complex presentations, 317 
Conception, signs of, 133 
Constipation in pregnancy, 188 
[Constriction of uterus, tetanoid, 350] 
Continued fever in pregnancy, 207 
Convulsions (puerperal). (See Eclamp- 
sia.) 
Corps reticule, 97 
Corpus luteum, 74 
Cranioclast, 487 
Craniotomy, 484 

cases requiring, 490 
comparative merits of, and cephalo- 
tripsy, 493 
description of cejmalotripsy, 494 
extraction of head by craniotomy for- 
ceps, 496 
method of perforating, 492 
perforators, 486 

perforation of after-coming head, 493 
religious objections to, 484 



Craniotomy forceps, 488 

Crotchets, 486 

Cystocele, obstructing labor, 347 



DEATH, apparent, of new-born child. 
(See Infant.) 
Death, sudden, during labor and the puer 
peral state, 607 
from air in the veins, 608 
functional causes of, 608 
organic causes of, 607 
Decapitation of foetus, 497 
Decidua, 89 

at end of pregnancy, and after de- 
livery, 93 
cavity between d. vera and reflexa, 93 
divisions of, 89 
fatty degeneration of, as the cause of 

labor, 243 
formation of d. reflexa, 91 
structure of, 90 
Delivery, state of patient after, 524 
contraction of uterus after, 526 
management of patient after, 530 
nervous shock after, 524 
prediction of date of, 152 
signs of recent, 155 
state of pulse after, 524 
weight of uterus after, 526 
Diameters of foetal skull, 111 

of pelvis, 33 
Diarrhoea in pregnancy, 188 
[Diet, milk, in nursing mothers, 537] 

of lying-in women, 531 
Dilators (caoutchouc) in the induction of 
premature labor, 439 
in rigidity of cervix, 341 
Diphtheria in the puerperal state, 571 
Diseases of pregnancy, 183 
albuminuria, 192 
anaemia and chlorosis, 191 
carcinoma, 209 
cardiac diseases, 208 
chorea, 198 
constipation, 188 
diarrhoea, 188 
disorders of the nervous system, 

196 
respiratory organs, 190 
teeth, 190 

urinary system, 198 
displacements of the gravid ute- 
rus, 201 
epilepsy, 209 
eruptive fevers, 206 
fibroid tumors, 211 
hremorrhoids, 189 
icterus, 209 
leucorrhoea, 200 
ovarian tumor, 210 
palpitation, 191 
paralysis, 197 
pneumonia, 207 
pruritus, 200 



INDEX 



631 



Diseases of pregnancy — 

ptyalism, 189 

syncope, 191 

syphilis, 208 

varicose veins, 201 

vomiting (excessive), 184 
Dropsies affecting the foetus, 225 
Ductus arteriosus, 119 

venosus, 119 
j Dystocia from foetus, 353 

ECLAMPSIA, 550 
cause of death in, 553 
condition of patient between the at- 
tacks, 552 
confusion from defective nomencla- 
ture, 550 
exciting causes of, 555 
[intermittent, 559] 
obstetric management in, 558 
pathology of, 553 
premonitory symptoms of, 550 
relation of, to labor, 552 
results to mother and child in, 552 
symptoms of, 551 
transfusion in, 515 
Traube and Rosenstein's theory of, 

554 
treatment of, 555 
uraemic theory of, 550 
Ecraseur, use of, as a substitute for crani- 
otomy, 489 
Embolism. (See Thrombosis.) 
Embryotomy, 497 
Emotion, mental, as a cause of protracted 

labor, 328 
Epiblast, 94 

Epilepsy, in pregnancy, 209 
Epileptic convulsions, 550 
Ergot of rye, 331 

as a means of inducing labor, 438 
objections to use of, 331 
mode of administration, 331 
value of, after delivery, 281 
Eruptive fevers in pregnancy, 206 
Erysipelas, as a cause of puerperal septi- 
caemia, 577 
Ether in labor, 285 

[in the United States, 285] 
Exhaustion, importance of distinguishing 
between temporary and permanent in 
labor, 331 
Expression, uterine. (See Pressure.) 

of the placenta, 280 
Extra-uterine pregnancy, 163 

abdominal variety of, 173 

causes of, 165 

changes of the foetus in, 175 

classification of, 164 

diagnosis of abdominal variety, 

176 
diagnosis of tubal variety, 169 
gastrotomy in, 172, 177 
pseudo-labor in, 175 



Extra-uterine pregnancy — 

symptoms of rupture in, 168 
treatment after rupture, 172 
treatment of abdominal variety, 

178 
tubal variety, 166 
treatment of tubal variety, 170 

Evisceration, 498 



FACE presentation, 297 
causes of, 298 
diagnosis of, 299 
difficulties connected with, 305 
erroneous views formerly enter- 
tained of, 297 
mechanism of delivery in, 299 
mento-posterior positions in, 304 
prognosis in, 304 
treatment of, 304 
Fallopian tubes, 61 
False pains, character and treatment of, 

270 
Faradization, in apparent still birth, 535 
Fibroid tumor in pregnancy, 211 

obstructing labor, 344 
Fillet, 482 

in breech presentations, 296 
[Japanese, 484] 
nature of the instrument, 482 
objections to its use, 483 
Foetal head, anatomy of, 110 

induction of premature labor, for 
large size of, 435 
Foetal heart, sounds of, in pregnancy, 

142 
Foetus, anatomy and physiology of, 107 
[anencephalous, causing eneuresis, 

199] 
appearance of a putrid, 228 
appearance of, at various stages of de- 
velopment, 108 
at term, 109 
circulation of, 119 
changes in circulation of, as cause of 

labor, 242 
changes in position of, during preg- 
nancy, 113 
death of, 228 

detection of position in utero by pal- 
pation, 113 
early viability of, 229 
excessive development of, as a cause 

of difficult labor, 364 
explanation of its position in utero, 

114 
functions of, 116 
nutrition of, 116 
pathology of, 222 
position of, in utero, 112 
respiration of, 118 

signs and diagnosis of death of, 228, 
493 
Fontanelles, 110 
Foot, diagnosis of, 289 



632 



INDEX 



Foot presentations. (See Pelvic presenta- 
tions.) 
Foramen ovale, 119 
Forceps, 458 

action of, 462 

advantages of pelvic curve in, 459 

[application at inferior strait, 478] 

[at superior strait, 480] 
application of, to after-coming head in 

breech presentations, 295 
application of, within the cervix, 343 
[carried over abdomen, to complete 

delivery of head, 481] 
cases in which a straight instrument 

should be used, 459 
dangers of, 335, 471 
dangers of, to child, 472 
description of, 458 
description of the operation, 465 
difference between high and low ope- 
rations, 464 
disadvantages of a weak instrument, 

461 
frequent use of, in modern practice, 

333, 458 
high operations, 470 
long, 460 
preliminary considerations before 

using, 464 
short, 458 
use of anaesthetics in forceps delivery, 

465 
use of in deformed pelvis, 382 
use of in difficult occipito-posterior 

positions, 308 
use of in protracted labor, 333 
[Forceps, Bedford's, 476] 
[Clemann's, 462] 
[Davis's, 475] 
[Elliot's, 476] 
[Hodge's, 474] 
[Meigs's Craniotomy, 496] 
[Sawyer's, 477] 
[Wallace's, 475] 
[White's, 476] 
Forceps-saw, 489 

[Forcipe compressore, Assalini's, 487] 
Fossa navicularis, 44 
Funis. (See Umbilical cord.) 



GALACTAGOGUES, 541 
Galactorrhcea, 542 
Galvanism as a means of inducing labor, 

438 
Gangrene of limbs from arterial obstruc- 
tion, 594 
Gastrotomy, after rupture of uterus, 425 
in extra-uterine pregnancy, 171, 179 
Gastro-elytrotomy. (See Laparo-elytrot- 

omy.) 
Generative organs, in the female, 41 

division according to function, 41 
Germinal vesicle, disappearance of, after 
impregnation, 87 



Gestation. (See Pregnancy.) 
Graafian follicle, 65 

structure of, 67 



HEMATOCELE, obstructing labor, 348 
Haemorrhoids, in pregnancy, 189 
[Hand, introduction of, in occipito-poste- 
rior positions, 308] 
Hand-feeding of infants, 546 
ass's milk in, 546 
artificial human milk in, 547 
causes of mortality in, 546 
cow's milk in, and its prepara- 
tion, 546 
goat's milk in, 546 
method of, 548 
[Harris on early puberty, 76] 
Head presentations, 255 

description of cranial positions 

in, 256 
division of, 256 
explanation of frequency of 1st 

position, 257 
frequency of, 256 
mechanism of 1st position, 359 
2d position, 264 
3d position, 265 
4th position, 266 
relative frequency of various po- 
sitions, 257 
Heart, diseases of, in pregnancy, 208 

hypertrophy of, in pregnancy, 130 
Hemorrhage, accidental, 399 

causes and pathology of, 400 

concealed internal, 401 

diagnosis, prognosis, and treatment 

of concealed internal, 400 
prognosis of, 401 
symptoms and diagnosis of, 400 
treatment of, 402 
Hemorrhage after delivery, 402 
causes of, 403 
constitutional predisposition to, 

407 
curative treatment of, 409 
from laceration of maternal struc- 
tures, 415 
nature's mode of preventing, 253, 

403 
preventive treatment of, 408 
secondary causes of, 405 
secondary treatment of, 415 
symptoms of, 407 
transfusion of blood in, 416 
Hemorrhage after delivery (secondary), 
416 
distinction between, and pro- 
fuse lochial discharge, 416 
local causes of, 417 
treatment of, 418 
Hemorrhage, unavoidable. (See Placenta 

previa.) 
Hernia, in labor, 347 
Hour-glass contraction of uterus, 405, [406] 



INDEX. 



633 



Hydatids of uterus, 215 
Hydramnios, 222 

Hydrocephalus of foetus, as a cause of dif- 
ficult labor, 361 
Hydrorrhea gravidarum, 214 
Hymen, 43 

[an obstacle to delivery, 44] 
Hypoblast, 94 
Hysteria during labor, 550 



INDUCTION of premature labor. (See 
Premature labor.) 
Inertia of the uterus, frequent child-bear- 
ing as a cause of, 327 
Infant, apparent death of, 533 

appearance of, in cases of apparent 

death, 534 
clothing of, 536 
evils of over-suckling, 536 
management of, 538 
management of, when food disagrees, 

549 
treatment of apparent death of, 534 
various kinds of food of, 549 
•washing and dressing of, 535 
Infantile mortality, diminution of, as a 
reason for more frequent use of forceps, 
335 
Inflammatory diseases affecting the foetus, 

225 
Insanity (puerperal), 559 

classification of, 559 
of lactation, 565 
of pregnancy, 560 
predisposing causes of, 560 
puerperal (proper), 562 
causes of, 562 
form of, 561 
prognosis of, 564 
post-mortem signs of, 565 
symptoms of, 565 
transient mania during delivery, 

561 
treatment of, 567 
treatment during convalescence, 

570 
question of removal to an asylum, 
569 
Insomnia in pregnancy, 196 
Intermittent fever affecting the foetus, 

224 
Intestines, disorders of, as influencing 

labor, 328 
Inversion of uterus. (See Uterus.) 
Irregular uterine contractions after labor, 
405 
as a cause of lingering labor, 
329 
Irritable bladder in pregnancy, 199 
Ischium, planes of the, 38 



"JAUNDICE in pregnancy, 209 
41 



KIESTEIN, 132, [133] 
Knots on the umbilical cord, 221 
Knee presentation, 288 
Kyphotic deformity of pelvis, 373 



LABIA major a, 41 
Labia minora, 42 
Labor, 242 

age, influence of, on, 328 

anaesthesia in, 282 

arrest of, 155 

causes of, 242 

causes of precipitate, 338 

causes of protracted, 326 

character and source of pain in, 248 

character of false pains, 270 

dilatation of cervix in, 246 

duration of, 254 

effect of uterine contractions in, 244 

evil effects of protracted, 324 

induction of. (See Premature labor.) 

influence of stage of, in protracted, 
325 

management of, in deformed pelvis, 
381 

management of natural, 268 

management of third stage of, 278 

mechanism of, in head presentation, 
256 

obstructed by faulty condition of the 
soft parts, 339 

period of day at which labor com- 
mences, 255 

phenomena of, 242 

position of patient during, 272 

preparatory treatment, 268 

precipitate, 338 

prolonged and precipitate, 324 

rupture of membranes in, 246 

stages of, 249 

symptoms of protracted, 326 

treatment of protracted, 329 
Lactation, defective secretion of milk in, 
541 

diet of nursing women during, 539 

excessive flow of milk in, 542 

importance of to mother, 537 

importance of wet-nursing to child, 
537 

insanity of, 565 

management of, 538 

means of arresting secretion of milk 
in, 540 

period of weaning in, 540 
Lamina? dorsales, 95 
Laparo-elytrotomy, 511 
Lead-poisoning, affecting the foetus, 224 

as a cause of abortion, 234 
Leucorrhoea, in pregnancy, 200 
Lever. (See Vectis.) 
[Line, dark abdominal, in negro, 138] 
Liquor amnii, 98 

uses of, 99 



634 



INDEX. 



Liquor amnii — 

source of, 99 
deficiency of, 223 
Lochia, 528 

variation in amount and duration of, 

529 
occasional fetor of, 529 
Lying-in hospitals, mortality in, 571 
Lypothemia, 191 



MALPRESENTATIONS, peculiar form of 
bag of membranes in, 288 
Mammary abscess, 542 

antiseptic treatment of, 544 
signs and symptoms of, 543 
treatment of, 543 
changes during pregnancy, 136 
their diagnostic value, 138 
glands, 69 

their sympathetic relations with 
the uterus, 71 
[McKnight's operation, 171] 
Measles, affecting the foetus, 224 

in pregnancy, 207 
Meconium, 122 
Membranes, artificial rupture of, 273 

puncture of, as a means of inducing 
labor, 437 
Menstruation, 71 
cessation of, 82 

during pregnancy, 134 
changes in Graafian follicle after, 72 
[increased by change of residence to 

a hot climate, 78] 
period of, duration, and recurrence, 

77 
purpose of, 82 
sources of blood in, 79 
theory of, 80 

quantity of blood lost in, 78 
vicarious, 82 
Mesoblast, 94 

[Milk, Alderney, too rich for young in- 
fants, 547] 
artificial human, 547 
ass's, 546 

cow's, and its preparation, 546 
defective secretion of, 541 
excessive secretion of, 542 
goat's, 546 
means of arresting the secretion of, 

540 
secretion of, after delivery, 536 
Milk-fever, 525 
Miscarriage. (See Abortion.) 
Missed labor, 181 
Moles, 232 

Monstrosity (double), 357 
classification of, 358 
mechanism of delivery in, 358 
Mons veneris, 41 
Montgomery's cups, 90 
Morning sickness, 135 
Mortality of childbirth, 523 



Mucous membrane of uterus. 
Uterus.) 



(See 



NERVOUS shock after delivery, 524 
Nervous system, changes in, during 
pregnancy, 131 
disorders of, in pregnancy, 196 
excitability of, in puerperal wo- 
men, 555 
Neuralgia in pregnancy, 196 
Nipple, 70 
Nipples, depressed, 541 

fissures and excoriations of, 541 
Nursing. (See Lactation.) 
Nutrition of foetus, 116 
Nymphae. (See Labia minora.) 



OBLIQUELY contracted pelvis, 373 
Obstetric bag, 269 
Occipito-posterior positions, difficult cases 
of, 307 
causes of face-to-pubis delivery 

in, 307 
forceps in, 308 
treatment of, 308 
vectis or fillet in, 308 
Omphalo-mesenteric artery and vein, 96 
Opiates, use of, after delivery, 530 
Os innominatum, 25 

Osteomalacia, as a cause of deformity, 367 
Osteophytes, formation of, during preg- 
nancy, 131 
Os uteri, dilatation of, as a means of in- 
ducing labor, 439 
occlusion of, in labor, 342 
Ovarian pregnancy. (See Extra-uterine 
pregnancy.) 
tumor in pregnancy, 210 
Ovariotomy in pregnancy, 210 
Ovary-; -63 

functions of, 71 
structure of, 63 
vascular arrangements of, 68 
Ovule, 68 

changes in, after impregnation, 87 
changes in, when retained in utero 

after its death, 232 
formation of, 66 
Oxytocic remedies, 330 



PAINS, after-, 529 
false, 250 
irregular and spasmodic as a cause of 

protracted labor, 329 
labor, 245 
Palpitation, in pregnancy, 191 
Pampiniform plexus, 56 
Paralysis in pregnancy, 197 

from embolism of the cerebral arteries, 

600 
from embolism of the main arteries of 
the limb, 600 



INDEX 



635 



Parovarium, 59 
Parturient canal, axis of, 37 
Pathology of decidua and ovum, 212 
Pelvis, alterations in, articulations of, 
during pregnancy, 31 
anatomy of, 25 
articulations of, 28 
axes of, 37 
Caesarean section in deformities of, 

385 
causes of deformity of, 366 
comparative estimate of turning and 

forceps in deformity of, 383 
craniotomy in deformity of, 385 
diagnosis of deformity, 379 
deformities of, 366 
development of, 39, 40 
difference according to race, 40 
difference in the two sexes, 32 
division into true and false, 32 
equally contracted, 368 
equally enlarged, 368 
forceps in deformity of, 382 
induction of premature labor in de- 
formity of, 385 
infantile, 39 
kyphotic, 374 
ligaments of, 28 
masculine, 369 
mechanism of delivery in deformed, 

377 
movements of the articulations of, 30 
obliquely contracted, 373 
planes of, 37 
Robert's, 374 

soft parts connected with, 40 
tumors of, 375 
turning in deformity of, 383 
undeveloped, 369 
Pelvic cellulitis and peritonitis, 616 
etiology of, 617 
importance of distinguishing 
the two forms of disease, 
617 
connection with septicaemia, 

618 
opening of abscess in, 623 
prognosis of, 622 
relative frequency of the two 

forms of disease, 619 
results of physical examina- 
tion, 620 
seat of inflammation in cellu- 
litis, 618 
seat of inflammation in peri- 
tonitis, 619 
suppuration in, 621 
symptomatology, 619 
terminations of, 621 
treatment of, 622 
two distinct forms of disease, 
617 
presentations, 286 

application of forceps to the after- 
coming head in, 295 



Pelvic presentations — 
causes of, 286 
danger to child in, 294 
diagnosis of, 287 
frequency of, 286 
management of impacted breech 

in, 296 
mechanism of, 289 
prognosis in, 287 
treatment of, 293 
Pelvimeters, various forms of, 379 
Perchloride of iron, injection of, in post- 
partum hemorrhage, 414 
[Perforator, Meigs's, 486] 

[rotary, 486] 
Perforators, 485 
Perineum, 411 

distension of, in labor, 252, 275 
incision of, 276 
laceration of, 277 
relaxation of, 275 

rigidity of, as a cause of protracted 

labor, 343 

Peritonitis, pelvic. (See Pelvic cellulitis.) 

Peritonitis, puerperal. (See Septicaemia.) 

Phlegmasia dolens. (See Thrombosis, 

peripheral venous.) 
Placenta, 100 

adhesion of, after delivery, 407 

degeneration of, 106 

detachment of, in labor, 253 

expression of, 280 

foetal portion of, 101 

form of, in man and animals, 100 

functions of, 106 

maternal portion of, 104 

minute structure of, 101 

pathology of, 218 

sinus system of, 103 

sounds produced during separation of, 

147 
treatment of adherent, 411 
Placenta membranacea, 218 
Placenta praevia, 388 
causes of, 388 

causes of hemorrhage in, 391 
natural termination of labor in, 

393 
pathological changes of placenta 

in, 392 
prognosis in, 384 
sources of hemorrhage in, 390 
summary of rules of treatment 

in, 398 
symptoms of, 389 
treatment of, 394 
turning in, 455 
Placenta succenturia, 218 
Placentitis, 219 
Plugging of vagina, 239 
Plural births, 157, 353 

arrangement of placentae and 

membranes in, 159 
causes of, 159 
diagnosis of, 160 



636 



INDEX. 



Plural "births — 

relative frequency of, in different 

countries, 158 
sex of children in, 158 
treatment of, 354 
Pneumonia in pregnancy, 207 
" Polar globule," 87 
[Polypus, an obstacle to delivery, 346] 
Position of cranium in head-presentation. 

(See Head presentation.) 
Post-partum hemorrhage. (See Hemor- 
rhage.) ' 
Pregnancy, 123 
abnormal, 157 
alteration of color of vaginal mucous 

membrane as a sign of, 142 
ballottement as a sign of, 141 
changes in the blood during, 129 
changes in the liver, lymphatics, and 
spleen during, 131 

in the urine during, 132 
[complicated with ovarian tumor, 210] 
deposits of pigmentary matter during, 

138 
differential diagnosis of, 148 
dress of patient in, 268 
duration of, 151 
enlargement of abdomen as a sign of, 

139 
extra-uterine. (See Extra-uterine 

Pregnancy.) 
foetal movements in, 139 
formation of osteophytes during, 131 
hypertrophy of the heart during, 

130 
in cases of double uterus, 57 
in the absence of menstruation, 135 
intermittent uterine contractions as a 

sign of, 140 
[nitrous oxide safely given in, 190] 
ptyalism in, 189 
prolapse of the uterus in, 201 
protraction of, 153 
pruritus in, 200 
quickening, 139 
sickness of, 135 
signs and diagnosis of, 133 
sounds produced by the foetal move- 
ments in, 147 
spurious, 150 

sympathetic disturbances of, 135 
uterine fluctuation in, 142 
vaginal signs of, 141 
pulsation in, 141 
Premature labor, 224 

history of the operation of induc- 
tion of, 435 
induction of, 435 

in deformed pelvis, 388 
injection of carbonic acid gas as a 

means of inducing, 441 
insertion of flexible bougie as a 

means of inducing, 441 
objects of the operation of induc- 
tion of, 435 



Premature labor — 

oxytocics as a means of inducing, 

438 
period for the induction of, in de- 
formed pelvis, 387 
precautions as regards the child 

in the induction of, 442 
puncture of the membranes as a 

means of inducing, 437 
separation of the membranes as a i 

means of inducing, 440 
vaginal and uterine douches as a 
means of inducing, 440 
Pressure as a means of inducing uterine 
contractions, 332 
mode of applying, 333 
Prolapse of umbilical cord. (See Umbili- 
cal cord.) 
Ptyalism in pregnancy, 189 
Puerperal convulsions. (See Eclampsia.) 
fever. (See Septicaemia.) 
mania. (See Insanity.) 
state, 523 

after-treatment in, 533 
diet and regimen in, 531 
diminution of uterus in, 526 
importance of prolonged rest in, 

532 
secretions and excretions in, 525 
temperature in, 525 
Pulmonary arteries, anatomical arrange- 
ment of, as favoring thrombosis, 597 
Pulse, state of, after delivery, 524 



QUICKENING, 151 
[Quinine as an oxytocic, 330] 



RACE as influencing the size of the foetal 
skull, 112 
Recto-vaginal fistula, 427 
Respiration of foetus, 118 
Respiratory chamber, 86 
Retroversion of the gravid uterus, 203 
Rickets as a cause of pelvic deformity, 367 
Rosenmuller, organ of. (See Parovarium.) 
Round ligaments of the uterus, 60 
Rupture of uterus. (See Uterus.) 



SACRUM, anatomy of, 27 
mechanical relations of, 27 
Salivation in pregnancy, 189 
Scarlet fever affecting the foetus, 224 
in pregnancy, 207 
in the puerperal state, 578 
Scybalse in the rectum obstructing labor, 

347 
Septicemia (puerperal), 570 
bacteria in, 581 
channels of diffusion in, 582 

through Avhich septic matter may 
be absorbed, 574 
cold in treatment of, 592 



INDEX 



637 



Septicaemia — 

conduct of practitioner in regard to, 

581 
contagion from other puerperal pa- 
tients as a cause of, 579 
description of, 586 
division into auto-genetic and hetero- 

genetic forms, 575 
epidemics of, 572 
history of, 571 
importance of antiseptic precautions 

in, 581 
influence of cadaveric poison as a cause 

of, 576 
influence of zymotic diseases in caus- 
ing, 577 
its connection with pelvic cellulitis 

and peritonitis, 618 
local changes in, 582 
mode in which the poison may be con- 
veyed to patients in, 580 
nature of septic poison, 581 
pathological phenomena in, 583 
pysemic forms of, 585 
sources of auto-infection in, 575 

of hetero-infection, 575 
symptoms of the intense forms, 586 
theory of an essential zymotic fever, 
573 
of identity with surgical septi- 
caemia, 573 
of local origin, 572 
transfusion of blood in, 514 
treatment of a, 588 
Warburg's tincture in the treatment 
of, 591 
Sex, discovery of, of foetus during preg- 
nancy, 143 
of foetus as influencing the size of the 
skull, 112 
Shoulder presentations, 309 
diagnosis of, 312 
division of, 310 
mechanism of, 314 
prognosis and frequency of, 312 
spontaneous version in, 314 
treatment of, 321 
[Siamese Twins, how born, 358] 
Sickness of pregnancy, 135 
[Silver uterine sutures, 509] 
[Sleep on inclined plane, for relief of dys- 
pnoea of pregnancy, 191] 
Smallpox affecting the foetus, 223 

in pregnancy, 207 
Smith's, Tyler, theory of labor, 243 
Spondylolithesis, 371 
Spontaneous evolution, 315 

version, 313 
Spurious pregnancy, 150 
diagnosis of, 151 
symptoms of, 150 
Symphyseotomy, 510 
Syncope during or after labor, 607 

in pregnancy, 191 
Syphilis affecting the foetus, 224 



Syphilis — 

as a cause of abortion, 233 

in pregnancy, 208 
Super-fecundation and super-fcetation, 161 
Sutures of foetal head, 110 



TEMPERATURE after delivery, 524 
[Thomas's operation, 171] 
Thrombosis (peripheral venous), 609 

changes in thrombi in, 618 

condition of the affected limb, 610 

detachment of emboli in, 614 

history and pathology of, 611 

progress of the disease, 611 

symptoms of, 610 

treatment of, 614 
(puerperal), 594 

arterial thrombosis and embolism, 
605 

cardiac murmur in pulmonary, 
602 

cases illustrating recovery from 
pulmonary, 600 

causes of death in pulmonary, 
603 

clinical facts in favor of pulmo- 
nary, 597 

conditions which favor throm- 
bosis in the puerperal state, 
595 

distinction between thrombosis 
and embolism, 596 

phlegmasia dolens a consequence 
of, 594 

post-mortem appearance of clots 
in pulmonary, 603 

question of primary thrombosis 
in the pulmonary arteries, 611 

question of recovery from pulmo- 
nary, 596 

symptoms of arterial, 605 

of pulmonary obstruction in, 
599 

treatment of arterial, 607 
of pulmonary, 604 
Thrombus. (See Hematocele.) 
Toothache in pregnancy, 190 
Transfusion of blood, 514 

addition of chemical reagents to 
prevent coagulation of fibrine, 
517 

cases suitable for the operation, 
519 

dangers of the operation, 519 

defibrination of blood in, 518 

difficulties of the operation, 516 

effects of successful transfusion, 
522 

history of the operation, 514 

immediate transfusion, 517 

method of injecting defibrinated 
blood, 522 

method of performing immediate 
transfusion, 520 



638 



INDEX 



Transfusion of blood — 

method of preparing defibrinated 

blood, 521 
mature and object of the opera- 
tion, 515 
secondary effects of, 522 
statistical results of, 519 
Tropics, influence of residence in, on labor, 

327 
Trunk, presentation of. (See Shoulder 

presentations.) 
Tumors, diagnosis of uterine and ovarian, 
149 
foetal, 226 

obstructing labor, 364 
Tunica albuginea, 64 
Turning, 442 

anaesthesia in, 446 
by combined method, 446 
by external manipulation only, 444 
cases suitable for the operation, 444 
for operating by combined 
method, 445 
cephalic, 446 

choice of hand to be used, 448 
history of the operation, 442 
in abdomino-anterior positions, 456 
in deformed pelvis, 383 
in placenta preevia, 396, 455 
method of cephalic, 443 

of performing by external manip- 
ulation, 445 
of podalic, 447 
object and nature of the operation, 

443 
period when the operation should be 

performed, 448 
podalic, 447, 451 
position of patient in, 447 
statistics and dangers of, 44 
value of anassthetics in difficult cases 
of, 457 
Twins. (See Plural births.) 
conjoined, 356 
locked, 355 



UMBILICAL cord, 106 
knots of, 107, 227 
ligature of, 277 
pathology of, 221 
prolapse of, 319 
causes of, 321 
diagnosis of, 321 
frequency of, 319 
prognosis of, 420 
postural treatment of, 322 
reposition of, 323 
Umbilical souffle, 145 

vesicle, 95 
[" Untimely ripped" in Shakespeare, 500] 
Urachus, 97 

Uraemia, in connection with eclampsia, 522 
in connection with puerperal insanity, 
563 



Urethra, 43 

Urine, changes in, during pregnancy, 132 

retention of, after delivery, 530 
Uterine fluctuation, as a sign of preg- 
nancy, 142 

souffle, 145 
Utero-sacral ligaments, 61 
Uterus, 47 

analogy of interior of, after delivery, 
and stump of an amputated limb, 
93 

anomalies of, 57 

arrangement of muscular fibres of, 52 

axis of, during pregnancy, 125 

changes in cervix during pregnancy, 
126, 141 

changes in form and dimensions of, 
during pregnancy, 123 

changes in mucous membranes of, 
after delivery, 527 

changes in mucous membranes of, 
after impregnation, 89 

changes in tissues of, during preg- 
nancy, 128 

changes in the vessels of, after de- 
livery, 527 

congestive hypertrophy of, 149 

contractions of, in labor, 245 

dimensions of, 49 

diminution in size of, after delivery, 
526 

distension of, as a cause of labor, 243 

distension of, by retained menses, 148 

fatty transformation of, after delivery, 
527 

intermittent contractions of, during 
pregnancy, 140 

internal surface of, 50 

inversion of, 429 

differential diagnosis of, 430 

production of, 430 

results of physical examination 

in, 430 
symptoms of, 429 
treatment of, 432 

ligaments of, 59 

lymphatics of, 56 

malposition of, as a cause of protracted 
labor, 328 

mode of action in labor, 245 

mucous membrane of, 53 

muscular fibres of, 52 

nerves of, 57 

[persistent intermittent contraction 
of, 141] 

regional division of, 50 

relations of, 48 

retroversion of gravid, 204 

[rupture of, gastrotomy, 426] 

size of, at various periods of preg- 
nancy, 124 

state of, in protracted labor, 327 

structures composing, 51 

rupture of, 419 

alterations of tissues in, 421 



ft 



INDEX 



639 



Jterus, rupture of — 

causes of, 421 

comparative result of various 
methods of treatment in, 426 

prognosis of, 424 

seat of laceration in, 420 

symptoms of, 423 

treatment of, 424, 427 
utricular glands of, 53 
vessels of, 56 
weight of, after delivery, 527 



ilTAGINA, 45 

f bands and cicatrices of, obstructing 
delivery, 343 

contraction of, after delivery, 526 

lacerations of, 427 

orifice of, 43 

structure of, 46 
[Vaginismus, with double vagina, 58] 
Varicose veins in pregnancy, 201 
iVectis, 482 

action of, 482 

cases in which it is applicable, 483 
Veins, entrance of air into, as a cause of 
sudden death after delivery, 608 



Venesection for rigidity of cervix, 340 

Version. (.See Turning.) 

Vesico-uterine ligaments, 61 

Vesico-vaginal fistula, 427 

Vestibule, 42 

Vicarious menstruation, 82 

Vomiting in pregnancy, 184 

Vulva, 41 

condition of, after delivery, 528 
oedema of, obstructing labor, 348 
vascular supply of, 45 

Vulvo-vaginal glands, 44 



WARBURG'S tincture, 591 
"Weaning. (See Lactation.) 
Wet-nurse, selection of, 537 
Wolffian bodies, 57, 108 
Wounds of the foetus, 226 



ZONA pellucida, 68 
Zymotic disease, affecting the foetus, 

223 
as a cause of septicaemia, 577 













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